Form Center

Special Needs Individual's Contact Information

First Name*
Last Name*
Nickname or Preferred Name
If William likes to be referred to as Bill, please indicate
Date of Birth*
Date of Birth
Age*
Address Line 1*
Address Line 2
City*
State*
Zip Code*
Telephone Number
Alternate Telephone Number
Email Address
Confirm Email Address
Continue

Gender*
Race*
Hair Color
Eye Color
Approximate Height
Example 5'10''
Approximate Weight
Example: 150
Scars, Marks, Tattoos, Identifiable Characteristics
Please describe scars, marks, tattoos, and any other identifying information that would help us more easily identify the Special Needs Individual. Include any medical ID bracelets, worn identification, and tracking devices. Example: a scar on the right cheek, walks with a limp, wears a medical ID bracelet on left wrist.
Continue |Go Back

Select the most serious condition*
1. ADD/ADHD
2. Alzheimer's Disease
3. Autism Spectrum Disorder
4. Dementia
1. Huntington's Disease
2. Mild Cognitive Impairment
3. Parkinson's Disease
4. Other
If "Other", please explain*
Example: special needs individual hasn't been diagnosed yet but displays symptoms of Autism Spectrum disorder; unresponsive to directed questions, no eye contact, animated arm movement, pacing, walking in circles, jumping up and down, loud outbursts, etc.
Other Notable Medical Conditions
Any other condition that you would like us to know about regarding the Special Needs Individual. Examples include; no sense of danger, blind or vision issues, deaf or hearing issues, nonverbal communicator, mental retardation, prone to seizures, other cognitive impairment
Preferred Method of Communication
If the Special Needs Individual communicates other than verbally, please list those alternative methods.
Individual Tracking Devices
List any personal tracking device carried by the Special Needs Individual.
Favorites, Hobbies, and Other Topics
Please list favorite places, activities, attractions. Think of places that offer the individual his/her favorite type of entertainment or stimuli. Does the individual like to walk to Publix on a daily basis? Would the individual get in the car and drive back to the home where he/she grew up? Additionally, list hobbies and favorite objects; toys, music, video games, likes or dislikes.
Continue |Go Back

Physician's First Name
Physician's Last Name
Physician's Telephone Number
The physician will only be contacted in cases of emergency.
Continue |Go Back

Leave This Blank: