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Special Needs Alert Form
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Special Needs Alert Form Person-Specific Information for First Responders
Individual's Name
*
(First, Middle Initial, Last)
Individual's Preferred Name
Address
*
(Street, City, State, Zip)
Date of Birth
*
Age
*
Does individual live alone?
*
Yes
No
Individual's Physical Description
Gender
*
Male
Female
Other
Height
*
Weight
*
Eye Color
*
Hair Color
*
Scars or Other Indentifying Marks
Emergency Contact Information
Name of Emergency Contact
*
(Parents/Guardians, Head of Household/Residence, or Care Providers)
Emergency Contact's Address
*
(Street, City/Town, State, Zip)
Emergency Contact's Phone Number(s)
*
Indicate Home, Work, and/or Cell
Name of Alternative Emergency Contact
Alternative Emergency Contact's Phone Number(s)
Indicate Home, Work, and/or Cell
Information Specific To The Individual
Individual's Primary Diagnosis/ Disability
*
(Check all that apply)
Down Syndrome
Bi-Polar Disorder
Autism
Schizophrenia
ADHD/ADD
Asperger Syndrome
Epilepsy
Tourette’s Syndrome
Depression
Other
If you answered, "Other," please explain:
Other Relevant Medical Conditions/Behaviors in addition to Primary Diagnosis/Disability
(Check all that apply)
No Sense of Danger
Blind
Deaf
Non-Verbal
Prone to Seizures
Cognitive Impairment
Combative/Aggressive
Other
If you answered, "Other," please explain:
Prescription Medications Needed and When Needed to be Taken:
Atypical Behaviors or Characteristics that may Attract or Require the Attention of Responders:
Sensory or Dietary Issues
(If any)
Identification Information, including Where it is Located
(i.e., Does the individual carry or wear jewelry, ID tags, ID card, Medical Alert Bracelets, etc.?
Does the Individual have any Tracking Devices?
Individual’s Favorite Toys, Objects, Music, Discussion topics, Likes or Dislikes
Submitted By
*
(Parent/Guardian)
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Email address
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