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2. 
3. Date
   Date
5. First Name
6. Middle Name
8. Last Name
9. Nickname
11. Birthdate
12. Gender
13. Race
14. Height
16. Weight
17. Hair Color
18. Eye Color
20. Identifying Features(tattoos, birthmarks)
21. Diagnosis/Special Concern
22. Please Attach a Current Photo of Person
23. Date of Photo
    Date of Photo
25. Address
27. City
28. State
29. Zip Code
31. Does this individual live alone?

    1. Yes
    2. No
33. Is this a Family Home or Group Home? Select One.

    1. Family Home
    2. Group Home
35. Phone Number
36. Cell Phone Number
38. Employer/School Address
40. Medications
42. How does this medication(s) affect actions, responses, senses, the potential for violence, etc.?
44. Please list any activations or triggers which may escalate an encounter? What actions should be avoided, if possible, by first responders?
46. Suggestions and techniques that can be taken to resolve a confrontation successfully:
48. This person is:

    1. Sensitive to light
    2. Likely to hide
    3. Sensitive to touch
    4. Likely to fight
    5. Subject to seizures
    6. Afraid of police/uniformed people
    7. Violent
50. Does this person tend to wander?

    1. Yes
    2. No
52. Favorite Attraction/ Location Where Person May Be Found
54. Communication Method if Non-Verbal/ Low-Verbal (picture cards, sign language, written words, communication device, etc):
56. Any additional information about person not already covered above :
58. Emergency Contact Information
60. Contact Person 1
61. Relationship
63. Address
65. City
66. State
67. Zip Code
69. Phone Number
70. Cell Phone Number
72. Contact Person 2
73. Relationship
75. Address
77. City
78. State
79. Zip Code
81. Phone Number
82. Cell Phone Number
84. Contact Person 3
85. Relationship
87. Address
89. City
90. State
91. Zip Code
93. Phone Number
94. Cell Phone Number
98. Responsible Party Completing This Form
100. I authorize the release of this information to Douglas County E-911, Douglasville Police Department, Douglas County Sheriff’s Office and Douglas County Fire Department for official use to help identify and assist me, my family member, ward, or client during an emergency. The form may also be used by program representatives for administrative purposes. I understand that completion of this form is voluntary and does not guarantee any special treatment. I acknowledge that I am responsible for the accuracy of the information and for updating the information when/if it changes.
102. Name
103. Email Address
105. Address
107. City
108. State
109. Zip Code
111. Phone Number
112. Cell Phone Number
114. Signature
115. Date
     Date
Leave This Blank:


117. 1. Receive an email copy of this form.
118. Email address

     This field is not part of the form submission.

119. Submit

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