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Autism Outreach Program

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Autism Awareness
Thank you for visiting our Autism Outreach page. Please take a moment to fill out the application to become a part of our voluntary program.
First Name*
Last Name*
Preferred Name
Does the Individual Live Alone?*
Date of Birth
Age
Address*
Building/Complex/Apartment
City*
State
Zip
Individual's Physical Description
Gender*
Height*
Weight*
Race*
Hair Color*
Eye Color*
Tattoos/Marks/Scars
Please Upload a Photo of the Individual
Additional Relevant Information
Prescription Medications Needed
Sensory or Dietary Issues
Other Medical Conditions
1. No Sense of Danger
2. Blind
3. Deaf
4. Non-Verbal
5. Prone to Seizures
6. Cognitive Impairment
7. Other
If Other, Please Explain
Additional Information For First Responders
Emergency Contact Information
Name of Emergency Contact (Parents, Guardians, Care Providers)
Emergency Contact Address
Emergency Contact Phone Numbers
Name and Phone Number of Alternate Emergency Contact
Information Specific To The Individual
Favorite Attractions or Locations Where the Individual May be Found
Behaviors/Characteristics of the Individual That May Attract the Attention of Responders
Individual’s Favorite Toys, Objects, Music, Discussion Topics, Likes, or Dislikes
Method of Preferred Communication (If Non-Verbal: Sign Language, Picture Boards, Written Words, Etc.)
Method of Preferred Communication (If Verbal: Words, Sounds, Sings, Phrases)
Identification (ID Card, Medical Alert Bracelet, Jewelry, Tags, Etc.)
Tracking Information (Does the Individual Have a Project Lifesaver, LoJack SafetyNet Transmitter Number?)
Individual May React Negatively If:
Additional Notes/Information