2. Following information describes the person with special needs.
4. First Name*
5. Preferred Name
6. Last Name*
8. Address*
10. Date of Birth*

    (MM/DD/YYYY)

11. Gender*
    -- Select One --FemaleMaleOther/Non-binary
13. Phone Number
15. Height*

    (Feet' Inches")

16. Weight*

    (Pounds)

17. Hair Color*
18. Eye Color*
20. Picture of Individual

    Please ensure photo includes ONLY the person with special needs

21. Medical Needs:

    (Diagnosis, Health Conditions, Important Medications)

23. Signs of Escalation/Triggers:

    (Recommended Do's and Don'ts, Likes and Dislikes)

24. If lost, may be found at:

    (likely places to go)

26. Method(s) of Communication:

    (i.e. pictures, hand signals, tablet, etc.)

28. Additional Information(Garage Code, Key box...):
30. Emergency Contact
32. Primary Contact*
33. Phone Number*
35. Secondary Contact
36. Phone Number
38. Consent for Information Release*

    1. I certify that the information above is correct and I give my permission to Fairfield Police Department to retain and/or distribute this information to first responders/law enforcement personnel for the sole purpose of identification and assistance to the person at risk.
40. Electronic Signature*
41. Date and Time*
    Date and Time

    Date and Time
43. Email Address
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field