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Autism or Other Special Needs and Emergency Contact Form

Name: Date Completed:
Gender:  Male Female Birthday:
Non-Verbal: Yes  No Height/Weight
Address: Email:
Parent/Guardian Name: Telephone-Home/Work/Cell
Parent/Guardian Name: Telephone-Home/Work/Cell
School/Employer/Other: Staff Contact:
Address, City & Zip Code Telephone:
Communication Methods-Verbal, Sign Language, Visuals, Software:    Describe Identifying Marks/Scars  
Medical Conditions-Autism, Seizures, Alzheimer's, Site/Hearing Impaired, etc:    
Medications:  Allergies:
Primary Care Physician: Telephone:
Address, City & Zip Code    
Important Information for Responders-key phrases or items that may help in a situation, i.e. cannot be left alone:
Behaviors that may be exhibited-i.e. runner; wanderer, eat non-edible items, head butts, etc:
Popular Destinations-i.e., Library, Swimming Pool, Restaurant, Store, etc:
Emergency Contact #1-Name, Telephone #, Relationship:
Emergency Contact #2-Name, Telephone #, Relationship:
Emergency Contact # 3- Name, Telephone #, Relationship:
GPS/Tracking Device Information:
Other:
Can we contact you to follow up? Yes  No      
If yes, best way to contact you: Email  Telephone 
Best time of the day to contact you:  Morning  Afternoon  Evening