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2. Is this your

   1. First Time to Provide Information
   2. Update to Previously Submitted Information
4. Name (First Middle Last)
5. Name to Call Me
6. Date of Birth
8. Race
   -- Select One --WhiteBlackHispanicAsian/Pacific Islander
9. Sex
   -- Select One --MaleFemale
10. Height
11. Weight
13. Hair Color
14. Eye Color
15. ID/DL # (include state)
16. Other Notable Characteristics
18. Address1
20. Address2
22. City
23. State
24. Zip
26. Daytime Location (School or Caretaker)
28. Address1
30. Address2
32. City
33. State
34. Zip
36. Disability

    1. Alzheimer's
    2. Autism
    3. Deaf
    4. Mentally Disabled
    5. Other
37. Organization

    1. ARC
    2. Council on Aging
    3. Autism Foundation
    4. Other
39. Emergency Contact Information
41. First Name
42. Last Name
44. Address1
46. Address2
48. City
49. State
50. Zip
52. Phone Number 1
53. Phone Number 2
55. First Name
56. Last Name
58. Address1
60. Address2
62. City
63. State
64. Zip
66. Phone Number 1
67. Phone Number 2
69. First Name
70. Last Name
72. Address1
74. Address2
76. City
77. State
78. Zip
80. Phone Number 1
81. Phone Number 2
83. Physician Information
85. First Name
86. Last Name
88. Address1
90. Address2
92. City
93. State
94. Zip
96. Phone Number 1
97. Phone Number 2
99. Information Specific to the Individual
101. Favorite attractions or locations the individual may be found:
102. Atypical behaviors or characteristics of the individual that may attract the attention of first responders:
103. Individuals favorite toys, objects, music, discussion topics, likes or dislikes:
104. Method of preferred communication if non-verbal (sign language, picture boards, written words):
106. Method of preferred communication if verbal (preferred words, sounds, songs, phrases):
107. Identification information (does the individual carry or wear jewelry, tags, ID card, medical alert bracelet, etc.?):
108. Tracking Information (Does the individual have an EmFinders or LoJack SafetyNet transmitting number?):
109. Likes/Dislikes (including approach and de-escalation techniques):
111. Medications:
Leave This Blank:


113. 1. Receive an email copy of this form.
114. Email address

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115. Submit

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