1

 Image of Person with Special Needs

Please upload a face photo. Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

2

 Name of Person

Name of Person

First

Last

3

 Address

Address

Street

Zip

4

 Phone

Phone

Cell Phone #

Cell Provider

5

School/Work 

School/Work

Address

Phoneext.

6

 Emergency Contact(s)

Emergency Contact(s)

Name	Phone ext.
Address	Relationship
Name	Phoneext.
Address	Relationship
Email Address	Email Address

7

 Details 

Details

Race	Skin Tone
Date of Birth	Height
Weight	Eye Color
Hair Color	Hair Style
Use of Mobility Device	Scars/Marks/Tattoos/Identification Worn

8

 Medical

Disability/Illness

9

 Please list any specific medical concerns and details:

(Medical History, medications, allergies, primary care physician, preferred hospital)

Please list any specific medical concerns and details: (Medical History, medications, allergies, primary care physician, preferred hospital)

10

Can the Individual Drive?

Can the Individual Drive?

Yes

No

11

 Vehicle Information

Vehicle Information

Vehicle

Driver's License Number

Driver's License State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

12

 Locations Person May Frequent

(Please list any information you think would be helpful.)

Locations Person May Frequent (Please list any information you think would be helpful.)

13

Method of Communication/Best Method of Approach

Method of Communication/Best Method of Approach

Best methods of communication:	Best method of approach:
Behaviors exhibited when upset/frustrated:	Best way to calm:
Other helpful advice or comments not covered on this form:

14

Do you authorize the Clayton Fire Department to contact you to participate in their Special Needs Tracking and Awareness Response System?

Do you authorize the Clayton Fire Department to contact you to participate in their Special Needs Tracking and Awareness Response System?

Yes

No

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2. Email Address

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