Riviera Beach Police Department Persons with Disabilities Registry

The form below is to be filled out with information about the person with autism or other cognitive impairment. This form will be sent directly to the Community Services Unit of the Riviera Beach Police Department. The information will be kept confidential and made available only to law enforcement entities. This process will allow officers who are responding to an incident involving a person registered in the Persons with Disabilities Registry to appropriately prepare for and handle the situation based on the information provided. Ultimately, through the RBPD Persons with Disabilities Registry, we aim to improve these interactions for all parties involved.

For more information, please contact the Riviera Beach Police Department’s non-emergency number at (561) 845-4123, reach out directly to Officer Knight with the Community Policing Division at (561) 635-7587, or email us at Alerts@rbpublicsafety.org.

To have a person removed from the program or to make any updates/changes to their information, please email Alerts@rbpublicsafety.org. Be sure to include the reason for removal or the updated information, along with your contact details for any follow-up questions we may have.

Please check that you understand that:*

I am registering for myself or am a parent or legal guardian and have proof to upload Proof of GuardianshipI have compiled all medical documents to certify the disability or condition into one PDF to upload

Individual's Information

Full Name*

First NameLast Name

Preferred Name (Nickname)

Date of Birth*

Date

Does the individual live alone?*

YesNo

Email

example@example.com

Phone Number*

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If you are the guardian, please upload proof of guardianship.

Note: Photo must be passport-style portrait that has a white or off-white background. No other persons or elements by them or in the background.

Upload Image Here

Physical Description

GenderRequired*

Height*

Weight*

Race or Ethnicity*

Eye Color*

Hair Color*

Scars, marks, tattoos, body markings, amputations.

Vehicle Description (If applicable)

Vehicle Type

Year (4-digit)

Make

Model

Color

State

License Plate Number

Medical Conditions

Please tell us about other relevant medical conditions the individual may have.

If other, please explain.

Prescription medications needed.

Sensory or dietary issues, if any.

Additional information first responders may need.*

Please upload medical diagnosis (proof of disability). PDF file only*

Emergency Contact

Parents, guardians, head of household/residence, or care providers.

Primary Emergency Contact*

First NameLast Name

Relationship*

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Alternate Emergency Contact

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Specific Information

Favorite attractions or locations where the individual may be found

Atypical behaviors or characteristics of the Individual that may attract the attention of Responders

Individual's favorite toys, objects, music, discussion topics, likes, or dislikes

Method of Preferred Communication. (If nonverbal: Sign language, picture boards, written words, etc. If verbal: preferred words, sounds, songs, phrases they may respond to)

Identification Information. (i.e. Does the individual carry or wear jewelry, tags, ID card, medical alert bracelets, etc.?):

Tracking Information. (Does the individual have a Project Lifesaver or LoJack SafetyNet Transmitter Number?):

I may react negatively if...

Additional Notes or Information