Autism Outreach Program

2. Autism Awareness
   

4. 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.

6. First Name*

7. Last Name*

9. Preferred Name

10. Does the Individual Live Alone?*

12. Date of Birth

13. Age

15. Address*

17. Building/Complex/Apartment

19. City*

20. State

21. Zip

25. Individual's Physical Description

27. Gender*

28. Height*

29. Weight*

30. Race*

32. Hair Color*

33. Eye Color*

34. Tattoos/Marks/Scars

36. Please Upload a Photo of the Individual

40. Additional Relevant Information

42. Prescription Medications Needed

44. Sensory or Dietary Issues

46. Other Medical Conditions

    1. No Sense of Danger
    2. Blind
    3. Deaf
    4. Non-Verbal
    5. Prone to Seizures
    6. Cognitive Impairment
    7. Other
47. If Other, Please Explain

49. Additional Information For First Responders

53. Emergency Contact Information

55. Name of Emergency Contact (Parents, Guardians, Care Providers)

57. Emergency Contact Address

59. Emergency Contact Phone Numbers

60. Name and Phone Number of Alternate Emergency Contact

64. Information Specific To The Individual

66. Favorite Attractions or Locations Where the Individual May be Found

68. Behaviors/Characteristics of the Individual That May Attract the Attention of Responders

70. Individual’s Favorite Toys, Objects, Music, Discussion Topics, Likes, or Dislikes

72. Method of Preferred Communication (If Non-Verbal: Sign Language, Picture Boards, Written Words, Etc.)

74. Method of Preferred Communication (If Verbal: Words, Sounds, Sings, Phrases)

76. Identification (ID Card, Medical Alert Bracelet, Jewelry, Tags, Etc.)

78. Tracking Information (Does the Individual Have a Project Lifesaver, LoJack SafetyNet Transmitter Number?)

80. Individual May React Negatively If:

82. Additional Notes/Information

Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit

* indicates a required field