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Sunny Isles Beach Police Department

autism@sibpd.net

18070 Collins Avenue, Sunny Isles Beach, FL 33160

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Autism Outreach Program

Name

Date of Birth

Home Address

Does the individual live alone?

School

Phone Number

Gender

Race

Height

Weight

Age

Eye Color

Hair Color

Scars, Marks, Tattoos, Piercings

Work Address

Work Phone

Vehicle Information

Vehicle Make

Vehicle Model

Vehicle Tag

Vehicle Color

Stickers, Decals, Damage, etc

Other Relevant Medical Conditions

No sense of danger

Deaf

Cognitive Impairment

Sight and/or sound sensitive

Non-Verbal

Prone to Seizures

Blind

Intellectual Disability

Other

Other Medical Conditions

Prescription Medication Needed

Sensory or Dietary Issues

Emergency Contact - Parent, Guardian, Head of Household, Care Provider

Emergency Contact Name

Emergency Contact Relationship to Individual

Emergency Contact Address

Emergency Contact Primary Phone Number

Emergency Contact Secondary Phone Number

Emergency Contact Email

Alternate Emergency Contact - Parent, Guardian, Head of Household, Care Provider

Alternate Emergency Contact Name

Alternate Emergency Contact Relationship to Individual

Alternate Emergency Contact Address

Alternate Emergency Contact Primary Phone Number

Alternate Emergency Contact Secondary Phone Number

Alternate Emergency Contact Email

Locations/Attractions individual may be found

Individual Likes/Dislikes (toys, music, objects, topics, etc.)

If Non-Verbal, Method of Preferred Communication (sign language, picture boards, written words, etc.)

If Verbal, Method of Preferred Communication (preferred words, sounds, songs, phrases)

Identification Information (Does the individual carry an identification card, wear jewelry tags, medical alert bracelet, etc?)

Tracking Information (Does the individual have a Project Lifesaver or Lojack SafetyNet transmitter number?)

Atypical behaviors/characteristics of the individual that may attract the attention of first responders

Additional information for first responders

Autism Decal

Would you like to receive a decal to display on your car, residence window or door to alert Sunny Isles Beach officers that someone in the home has Autism?

Yes

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Document Signers

- Signature
- Police Department