Special Needs Emergency Contact Form

We have implemented this program to help our dispatchers to relay the most accurate and helpful information to our responders. The information you give us in this form will be associated with the address you also give in the form, therefore any time there is a call for responders at your address anyone responding will be aware of your loved ones’ special needs. These forms will need to be updated yearly to make sure we maintain accurate information to make sure the best care is given to your loved ones

- Step 1 of 2

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Name of Child/Adult with Special Needs *

First

Last

Attach Photo

Click or drag a file to this area to upload.

Attache a photo of the Child/Adult with Special Needs

Layout

DOB

Eye Color

Height

Weight

Hair Color

Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

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Phone

Phone Serivce Provider

ATT, Verizon, T-Mobile, etc.

Method of Communications

If Non-Verbal:Sign Language, Picture Board, Written Word, Etc

Identification Worn

Jewelry/Medic Alert, clothing tags, ID card, tracking monitor, etc

Current Prescriptions

Including Dosage

Sensory/Medical/Dietary Issues and Requirements

If Any

Inclination of wandering behaviors or characteristics that may attract

Attention:

Favorite attractions or locations where person may be found, if missing:

Like/Dislikes

Including approach and de-esclation techniques

Next

Layout

Medical Care Providers

Phone

Medical Care Providers

Phone

Parent/Caregiver Info

Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Email

Emergency Contact Info

Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Submit