Tooele County Safety Roster

Tooele County Safety Roster

Tooele City Police Department has created our voluntary safety roster to assist families with Autism, other developmental disabilities, and mental health diagnoses. In partnership with the Tooele County First Responders, this program promotes communication and quick access to important information regarding a person who has indications of Autism, developmental disabilities, and mental health diagnoses. This critical information will help first responders before and after they arrive at a scene. Please share all information you feel comfortable providing. Complete this form yearly to ensure accurate and up-to-date information is available for first responders. You will receive a notification to refresh your information at the end of each year.
Name of the person completing this form*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Relationship to Person with Disability*
Submission Type*

Information of the person with a disability
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Race*
Gender*
Height*
For 5'8" you would type 508
Weight*
Hair Color*
Eye Color*
Identifying Features*
Scars, Birthmarks, Tattoos, other Identifying Features
Current Photo*

Upload a current photograph that only has the person you are submitting for in the picture.
Cancelof
Date Photo Was Taken

MonthDayYear
Date
Disability Information
Primary Diagnosis*
Diagnosis*
Co-Existing Diagnosis*
Co-Existing Diagnosis*
Note N/A If not applicable
Communication Method*
What is this person's primary language?*
Please provided this person primary language*
If they are non-verbal, please describe the best way to communicate to them.*
Will they respond to their name being called?
Residence Information
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Is there weapons in the home?*
Are the weapons secured?*

Work & School Information
Does this person attend a school or college?*
School Name*
What is this person's level of school enrollment?*
What is the address of the school?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is the school point of contact?*

First NameLast Name
What is the school point of contact's phone number?*
Please enter a valid phone number.Format: (000) 000-0000.
Work Information
Does this person work or volunteer?*
What is the name of their work place?*
What is the address of their work place?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is their workplace point of contact?*

First NameLast Name
What is their work places point of contact's phone number?*
Please enter a valid phone number.Format: (000) 000-0000.

Vehicle and Transit Information
Does this person drive or own a vehicle?*
How many vehicles does this person own, use or operate?*
Vehicle #1 Year*
Vehicle #1 Make*
Vehicle #1 Model*
Vehicle #1 License plate number and state of issue*
Vehicle #2 Year*
Vehicle #2 Make*
Vehicle #2 Model*
Vehicle #2 License plate number and state of issue*
Vehicle #3 Year*
Vehicle #3 Make*
Vehicle #3 Model*
Vehicle #3 License plate number and state of issue*
Does this person use other types of transportation? (School bus, public transit?)*
What types of transportation does this person use?

Other

Additional Information
Add any additional information you would like us to know that could help first responders?

Release of Information
I hereby give my permission for any first responder agency (including but not limited to police, fire, rescue, EMS, dispatch center, and search and rescue personnel) to retain and distribute the information contained in this registration form to other first responder personnel for the sole purpose of identifying and protecting the person identified above in an emergency or crisis situation. By signing below, you are agreeing to the release terms posted above.
Signature
Should be Empty:

Information of the person with a disability