Child Safety Profile Questionnaire

Child Safety Profile Questionnaire

Complete this to help create your child’s personalized safety materials and public profile—answer only what you want included and confirm you’re the parent/legal guardian (or authorized).
Intro / Consent
How we use this information
Authorization and consent
Child Basics
Child's Full Name

First NameMiddle NameLast Name
Name / Nickname for Public Display
Pronouns
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Recent Child Photo

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General Physical Description
Preferred Product / Profile Theme
Theme Description
Favorite Colors

Other
Favorite Characters / Interests
Communication
How does the child communicate?

Other
If other, please explain
Speaking level
How well does the child understand spoken directions?

1

2

3

4

5

6

7

8

9

10

1 is Needs full support, 10 is Understands easily
Helpful words, signs, gestures, AAC prompts, or phrases
Best way for an unfamiliar adult to communicate with the child
Does the child respond to their name?
Languages understood or used
Safety and Elopement
Risk of wandering or elopement
What seems to trigger or come before wandering?
Where or toward what might the child be drawn?
Water attraction or related risk
If yes or unsure, describe the water-related concern
Traffic awareness
Stranger awareness
If a finder locates the child, what should they do first?
If a finder locates the child, what should they never do?
Behaviors the child may exhibit

Other
Sensory Needs and Distress Support
Sensory Triggers

Other
If other, please explain
Signs of Distress or Overwhelm
What Helps Them Calm or Regulate
Best Way to Support Them During Distress
Tolerance for Police, Sirens, Uniforms, or Emergency Vehicles
Explain tolerance and list comfort items, favorite topics, motivators, and touch preferences or boundaries, including whether to avoid grabbing or restraining unless needed for immediate safety
Does the child have any allergies?
If yes, list the allergies
Medical conditions relevant in an emergency
Is there a seizure risk?
If yes, describe the seizure response plan
Mobility, hearing, vision, or assistive-device needs

Other
Emergency Contacts
Primary Parent/Guardian Full Name

First NameMiddle NameLast Name
Relationship to Child
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Secondary Emergency Contact Full Name

First NameMiddle NameLast Name
Secondary Contact Relationship
Secondary Contact Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Emergency Contact Full Name

First NameLast Name
Additional Emergency Contact Relationship
Additional Emergency Contact Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Design Requests
Inspiration or Reference Image

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Review and Authorization
I confirm that the information provided is accurate to the best of my knowledge.
I agree to notify Idle Minds Designs if emergency contacts, allergies, medical needs, or other critical information changes.
Typed guardian name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Electronic signature
Thank you! Idle Minds Designs will review your information and send a proof for your approval before your child’s profile is published or encoded. Please do not include information in the public profile that you are not comfortable sharing with anyone who scans or taps the tag.
Should be Empty:

Child Safety Profile Questionnaire

Intro / Consent

Child Basics

Communication

Safety and Elopement

Sensory Needs and Distress Support

Emergency Contacts

Review and Authorization