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2. 
3. 
5. Today's Date*
   Today's Date
7. Individual’s Name
9. First Name*
10. Last Name*
12. Address1*
14. City*
15. State*
16. Zip*
18. Date of Birth*
19. Age
20. Preferred Name
22. INDIVIDUAL’S PHYSICAL DESCRIPTION
24. Gender

    1. Male
    2. Female
25. Height
26. Weight
27. Eye Color
29. Hair Color
30. Scars or other identifying marks
32. Primary Diagnosis/Disability*
34. Other Relevant Medical Conditions / Behaviors in addition to Primary Diagnosis/Disability (check all that apply)

    1. No Sense of Danger
    2. Blind
    3. Deaf

    1. Non-Verbal
    2. Prone to Seizures
    3. Cognitive Impairment

    1. Combative/Aggressive
    2. Other (please explain)
36. Other-
38. Prescription Medications Needed
40. Sensory or Dietary Issues, if any
42. Additional Information First Responders may need
44. EMERGENCY CONTACT INFORMATION
46. Name of Emergency Contact (Parents/Guardians, Head of Household/Residence, or Care Providers):
48. First Name*
49. Last Name*
51. Address1*
53. City*
54. State*
55. Zip*
57. Primary Phone Number*
58. Secondary Phone Number
60. Name of Alternate Emergency Contact:
62. First Name*
63. Last Name*
65. Primary Phone Number*
66. Secondary Phone Number
68. INFORMATION SPECIFIC TO THE INDIVIDUAL
70. Method of Preferred NON-VERBAL Communication (sign language, picture boards, written words, communication devices, I-Pads, etc.):
72. Method of Preferred VERBAL Communication (preferred words, sounds, songs, phrases they may respond to):
74. Favorite attractions or locations where the individual may be found:
76. Atypical behaviors or characteristics of the individual that may attract the attention of Responders:
78. Individual’s favorite toys, objects, music, discussion topics, likes or dislikes:
80. Identification information, including where it is located (i.e., Does the individual carry or wear jewelry, tags, ID card, medical alert bracelets, etc?):
82. Tracking Information (Does the individual have any tracking devices?):
84. SUBMITTED BY (Parent/Guardian):*
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86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit

* indicates a required field