Autism Safety Program

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Autism Safety Program

Autism Safety Program is a project in partnership with the community and Summit County Sheriff's Office. This online program promotes communication and gives police quick access to important information about a person who displays a tendency to wander; such as Autism, Dementia or other disability with similar tendencies. This program provides information that is critical for law enforcement prior to an officer's arrival at a scene and/or prior to contacting an individual with disabilities. Rapid access to information such as their name, birthday, physical description, emergency contact information, known triggers and behaviors, etc. will help Officers during their initial response. Please share all information you feel comfortable providing. This form should be filled out yearly to ensure accurate information is available for first responders. You will receive a notification at the end of each year to refresh your information.

PERSON COMPLETING THIS FORM

Name:*

Phone:*

Email:*

Relationship to Person with Disability:*

PERSON WITH DISABILITY INFORMATION

Submission Type: ( Mark if this is a New Entry or Renewal )*

New Entry Renewal

First Name:*

Last Name:*

Cell Phone:*

Yes No

Cell Phone Number:*

State Issued ID:*

Yes No

State ID & Number:*

Race:*

Gender:*

Male Female

Date of Birth:*

Height:*

Weight:*

Hair Color:*

Eye Color:*

Identifying Features: ( Scars, Birthmarks, Tattoos, other Identifying Features )*

Other Names: ( nicknames, gaming name, etc )

File Attachments: ( Upload a current photograph that only has the person you are submitting for in the picture. )*

No File Chosen

File uploads may not work on some mobile devices.

DISABILITY INFORMATION

Primary Diagnosis*

Co-Existing Diagnosis: ( Mark NA if not applicable )*

Communication Method:*

Verbal Non-Verbal

Describe if Non Verbal: ( Mark NA if not applicable )*

Will They Respond To Their Name Being Called:*

Yes No

AUTISTIC CHARACTERISTICS ( Complete this section if person with disability is Autistic. )

Sensory Issues:

Seekers Sensory Avoidance

Touch:

Seekers Sensory Avoidance

Sounds:

Seekers Sensory Avoidance

Bright Lights:

Seekers Sensory Avoidance

Stimming Behavior: ( Mark NA if not applicable )

DISABILITY CHARACTARISTICS

Process Delays:*

Yes No

Fears: ( Mark NA if not applicable )*

Dislikes/ Triggers: ( Mark NA if not applicable )*

Favorite Objects /Topics*

Pre-Meltdown Signs: ( Mark NA if not applicable )*

Meltdown Behavior: ( Mark NA if not applicable )*

Calming Strategies That Work: ( Mark NA if not applicable )*

Prior Contact With Police: ( Mark NA if not applicable )*

Alcohol / Drug Issues:*

Yes No

Does the Family Have a Crisis Plan:*

Yes No

WANDERING

Prior Wandering Incident:*

Yes No

If Prone To Wandering, Where Have They Been Found: ( Mark NA if not applicable )*

Closest Water To Residence: ( Mark NA if not applicable )*

List All Lakes, Ponds, Streams, Pools, Etc: ( Mark NA if not applicable )*

Favorite Hiding Places At Home: ( Mark NA if not applicable )*

Favorite Hiding Places in Neighborhood/ Community: ( Mark NA if not applicable )*

SCHOOL INFORMATION

School Name: ( Mark NA if not applicable )*

Grade: ( Mark NA if not applicable )*

School Address: ( Mark NA if not applicable )*

School Contact Name: ( Mark NA if not applicable )*

School Contact Phone: ( Mark NA if not applicable )*

Bus Use*

School Bus Transit Bus None

RESIDENCE INFORMATION

Home Address:*

Address Line 1

City

State

ZIP Code

Phone:*

Weapons in the Home?*

Yes No

Weapons Properly Secured:*

Yes No Not Applicable

PRIMARY GUARDIAN / CARETAKER INFORMATION

Name:*

Relationship:*

Primary Phone:*

Secondary Phone: ( Mark NA if not applicable )

Place of Work: ( Mark NA if not applicable )*

Work Address: ( Mark NA if not applicable )*

Address Line 1

City

State

ZIP Code

SECONDARY GUARDIAN/CARETAKER INFORMATION

Name:*

Relationship:*

Primary Phone:*

Secondary Phone: ( Mark NA if not applicable )

Place of Work: ( Mark NA if not applicable )*

Work Address: ( Mark NA if not applicable )*

Address Line 1

City

State

ZIP Code

PRIMARY EMERGENCY CONTACT INFORMATION ( Other than previously identified Guardians )

Name:*

Relationship:*

Primary Phone:*

Secondary Phone: ( Mark NA if not applicable )

Address:*

Address Line 1

City

State

ZIP Code

VEHICLE INFORMATION

Vehicle 1 Make:

Vehicle 1 Model:

Vehicle 1 Year:

Vehicle 2 Make:

Vehicle 2 Model:

Vehicle 2 Year:

Add any additional information:

RELEASE OF INFORMATION

I, hereby give my permission for any first responder agency (including but not limited to police, fire/rescue/EMS/911 dispatch center, search and rescue personnel) to retain and distribute the information contained in this registration form to other first responder personnel for the sole purpose of identification and protection of the person identified above in an emergency or crisis situation.

By clicking the Release of Information box and typing your full name in the box below, you are agreeing to the release terms posted above.

RELEASE OF INFORMATION

Enter Your Full Name: ( Person submitting information )*

Today's Date:*