VMPD - Special Needs Registry

VMPD - Special Needs Registry

A Project in Safety by the Police Department. This is a Voluntary Submission Form for Residents Only. Please do not forget to attach a photo of the individual.
General Information about Individual
Full Name*
Date of Birth*

MonthDayYear
Date
Cell Phone Number
Address*
How does the Individual primarily Communicate?

VerbalNon-VerbalSign Language
Can the Individual Swim?

YesNo
Can the Individual Drive?

YesNo
Photo of Individual

Upload a JPG, JPEG, or PNG
Cancelof
Emergency Contact Information
Relationship to Individual
Full Name
Date of Birth

MonthDayYear
Date
Cell Phone
Address
Email
example@example.com
Secondary Emergency Contact Information
Relationship to Individual
Full Name
Date of Birth

MonthDayYear
Date
Cell Phone
Address
Interaction Guidance and Diagnosis
All Diagnoses
Other Medical Information/Allergies
List of Places to Look if Missing/Wandering
If encountered, the Individual may
Not SpeakNot Respond to their name or verbal commandTry to Run AwayAppear DeafAvoid Eye ContactRock, Pace, Spin, or Repeat PhrasesHave Fears/Obsessions with Flashing Lights, Sirens, or K-9sHold Hands Over Ears Due to Sound SensitivitesNot Answer QuestionsNeed Time to Process QuestionsAppear to be Under the InfluenceNot be Properly Dressed for the ElementsBe Overly Friendly/Trusting of othersBe Unaware of DangerHave Emotional/Physical Outbursts (Describe Below)
Other
Other
Other
Signature
Legal Guardian Name: (Print)*
Legal Guardian Signature*

Clear
VOLUNTARY SUBMISSION FORM: This is a voluntary submission form to be completed by an individual on their own behalf or by a legal guardian with authority to submit it on the behalf of another. The completion of this form is meant to aid police and emergency personnel in their response only and is not meant to convey any guarantee of outcome, promises or benefits from use of the form. This information supplied may be used in the event of a personal emergency. It is the responsibility of the submitter to ensure all information is truthful, valid, and up to date.
Filler's Email*
Once submitted, you will receive an email containing the response to this form, as well as a PDF copy that may be printed to keep as record of submission.
Should be Empty:

VMPD - Special Needs Registry

General Information about Individual

Emergency Contact Information

Secondary Emergency Contact Information

Interaction Guidance and Diagnosis

If encountered, the Individual may

Signature