2. First Name
3. Nickname
4. Last Name
6. Address1
8. Address2
10. City
11. State
12. Zip
14. DOB (MM/DD/YYYY)
    DOB (MM/DD/YYYY)
15. Race
    -- Select One --BlackLatinoAsianCaucasianOther
16. Gender
    -- Select One --MaleFemaleOther
18. Height
    -- Select One --5'5' 1"5' 2"5' 3"5' 4"5' 5"5' 6"5' 7"5' 8"5' 9"6'6' 1"6' 2"6' 3"
19. Weight*
20. Hair Color
21. Eye Color*
23. SSN:
25. Scars/Birthmarks/Tattoo's
27. Click to upload photo:
31. Primary Diagnosis:
32. Physician Name:
34. Phone Number:
35. Medications:
37. Prone to Seizures?
    -- Select One --YesNo
38. Communication:

    1. Verbal
    2. Non-Verbal
39. If non-verbal, mode of communication?
41. Level of Functioning
43. Will this person respond to name being called?
    -- Select One --YesNo
44. Prior Wandering Incident?
    -- Select One --YesNo
45. If yes, where has this person been located before?
47. List all pools, lakes, ponds, streams, drainage ponds, etc. in the area:
49. Favorite hiding place at home:
50. Favorite hiding place in neighborhood/community:
52. Sensory Issues:
    -- Select One --YesNo
53. Touch:
    -- Select One --YesNo
54. Sounds:
    -- Select One --YesNo
55. Bright Lights:
    -- Select One --YesNo
57. Eye Contact:
    -- Select One --YesNo
58. Processing Delays:
    -- Select One --YesNo
59. Aggression:
    -- Select One --YesNo
61. Stimming Behavior:
62. Fears:
64. Dislikes/Triggers
65. Favorite Objects/Topics:
67. Pre-meltdown Signs:
68. Calming Strategies:
70. Meltdown Behaviors:
72. Access to motor vehicle?
    -- Select One --YesNo
73. Make/Model
74. Registration Number:
76. Weapons in the home?
    -- Select One --YesNo
77. Weapons Secured?
    -- Select One --YesNo
78. Are restraints used by caretakers for safety?
    -- Select One --YesNo
80. Any other information you feel is pertinent to person at risk:
84. Emergency Contacts:
86. Contact #1:
88. First Name
89. Last Name
91. Relationship:
92. Home Phone:
93. Cell Phone:
95. Email Address
96. Address1
98. Address2
100. City
101. State
102. Zip
104. Contact 2:
106. First Name
107. Last Name
109. Relationship:
110. Home Phone:
111. Cell Phone:
113. Email Address
115. Address1
117. Address2
119. City
120. State
121. Zip
125. Agreement:

     I hereby give permission for any first responder agency (including but not limited to: Police, Fire, Rescue, EMS, 911 Dispatch Center, Search & Rescue Personel) to retain and distribute the information contained in this registration form to other first responder personnel for the sole purpose of identification and protection of the person identified above in an emergency or crisis situation.

127. Electronic Signature For Agreement Above:
131. Name of Person/Guardian completing form:
132. Date:
     Date:

     Date:
134. Email Address:
136. Info:

     Attn: Sgt. Lyman, 110 Church St., Chicopee, MA 01020. Please call (413)594-1700 if you have any questions or need assistance.

Leave This Blank:


138. 1. Receive an email copy of this form.
139. Email address

     This field is not part of the form submission.

140. Submit

* indicates a required field