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2. Personal Information for Individual with Special Needs
4. Legal Name
5. Nickname(s)
7. Address1
9. City
10. State
11. Zip
13. Date of Birth
14. Cell Phone
15. Home Phone
17. Race
18. Gender
19. Hair Color
20. Eye Color
22. Height
23. Weight
25. Scars/Birthmarks/Tattoos/Medical Alert Bracelet
27. Method(s) of Communication
29. Primary Language
30. School
31. Workplace
33. Driver’s License/ID Card
34. Vehicle’s Make/Model/Color
36. Upload Photo
40. Emergency Contact Information
42. Parent/Guardian
44. Address1
46. City
47. State
48. Zip
50. Cell Phone
51. Home Phone
53. Additional Parent/Guardian
55. Address1
57. City
58. State
59. Zip
61. Cell Phone
62. Home Phone
64. Special Needs/Disability Information Primary Diagnosis
66. Additional Diagnosis(s)
68. Medical Needs/Allergies
70. Describe Any Unique or Special Behaviors/Characteristics
72. Describe Best Approach Technique for Responders to Use
74. Describe what not to do when approaching (if applicable)
76. Favorite/Commonly Frequented Places
78. Safe Places Can Be Taken To
80. Describe Any Sensory, Medical or Dietary Issues
82. Does this individual have a history of running away?
84. Is this individual attracted to water?
85. Can this individual swim?
87. Additional Information
89. RELEASE OF INFORMATION

    I hereby give my permission to Pepper Pike Police Department to retain and distribute the information contained in this registration form to other First Responders, (including, but not limited to: Police, Fire, EMS, Rescue, and Dispatchers) for the sole purpose of identification and protection of the person identified above, in the event of an emergency or crisis.

91. First Name
92. Last Name
Leave This Blank:


94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit Submit and Print

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