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Special Needs Alert Form

2. Special Needs Alert Form Person-Specific Information for First Responders

4. Individual's Name*

   (First, Middle Initial, Last)

6. Individual's Preferred Name

8. Address*

   (Street, City, State, Zip)

10. Date of Birth*

11. Age*

12. Does individual live alone?*

    1. Yes
    2. No

14. Individual's Physical Description

16. Gender*

    1. Male
    2. Female
    3. Other

17. Height*

18. Weight*

20. Eye Color*

21. Hair Color*

23. Scars or Other Indentifying Marks

25. Emergency Contact Information

27. Name of Emergency Contact*

    (Parents/Guardians, Head of Household/Residence, or Care Providers)

29. Emergency Contact's Address*

    (Street, City/Town, State, Zip)

31. Emergency Contact's Phone Number(s)*

    Indicate Home, Work, and/or Cell

33. Name of Alternative Emergency Contact

35. Alternative Emergency Contact's Phone Number(s)

    Indicate Home, Work, and/or Cell

37. Information Specific To The Individual

39. Individual's Primary Diagnosis/ Disability*

    (Check all that apply)

    1. Down Syndrome
    2. Bi-Polar Disorder
    3. Autism
    4. Schizophrenia
    5. ADHD/ADD
    6. Asperger Syndrome
    7. Epilepsy
    8. Tourette’s Syndrome
    9. Depression
    10. Other
40. If you answered, "Other," please explain:

42. Other Relevant Medical Conditions/Behaviors in addition to Primary Diagnosis/Disability

    (Check all that apply)

    1. No Sense of Danger
    2. Blind
    3. Deaf
    4. Non-Verbal
    5. Prone to Seizures
    6. Cognitive Impairment
    7. Combative/Aggressive
    8. Other
43. If you answered, "Other," please explain:

45. Prescription Medications Needed and When Needed to be Taken:

47. Atypical Behaviors or Characteristics that may Attract or Require the Attention of Responders:

49. Sensory or Dietary Issues

    (If any)

51. Identification Information, including Where it is Located

    (i.e., Does the individual carry or wear jewelry, ID tags, ID card, Medical Alert Bracelets, etc.?

53. Does the Individual have any Tracking Devices?

55. Individual’s Favorite Toys, Objects, Music, Discussion topics, Likes or Dislikes

57. Submitted By*

    (Parent/Guardian)

Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit Submit and Print

* indicates a required field