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Autism Outreach Program
Name
*
Date of Birth
*
Home Address
*
Does the individual live alone?
*
Choose One
Yes
No
School
Phone Number
*
Email
*
Gender
*
Race
Choose One
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
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
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?
No
Yes
disregard this