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Register Someone with Autism/Dementia

Law enforcement is frequently called to find a wandering senior who is suffering from dementia or one of our young citizens who is suffering from some form of Autism.  We want to be able to respond compassionately as well as professionally.  By completing this form, you are helping local law enforcement know how to treat your loved one should you ever have an emergency.  With the information provided in the form below about your special needs family member, we will add a unique alert button to the address as well as their name in our closed records system.  If you should call for help, our 911 Communications Officers will inform responding deputies about the special needs so they may interact appropriately when encountering your family member.  We appreciate your assistance and hope this will help if you and/or family member ever have an emergency situation.

Please press the submit button at the bottom of the form to send directly to our Records Division. Click here to download and print the form.

* indicates required fields

Persons Information

* First Name:
Middle Name:
Nick Name:
* Last Name:
* E-mail:
* Street Address:
* City:
* Zip:
* Date of Birth:
* Race:
* Sex:
* Height:
* Weight:
* Eye Color:
* Hair Color:
Facial Hair:
* Primary Dexterity:
Right     Left
* Type of Condition: (i.e. Alzheimers, Dementia, Autism)
* Any Known Triggers:
* Does this person have a cell phone with them?
Yes     No
If yes, what is the phone number?
Who is the provider company?
* Does this person have a scent kit completed?
Yes     No
If yes, where is the scent kit located? (We recommend on top of the refrigerator)

Caregiver / Emergency Contact Information:

* Name
* Relationship
* Primary Contact Number
Secondary Contact Number
Primary Contact Number
Secondary Contact Number

Form Completed By:

* Name
* Relationship
* Phone Number
* Date