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