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This form allows families and guardians of individuals with dementia, autism spectrum disorder or other cognitive disorders to provide information to our safety services (fire and police) to be used only in the event of an emergency situation.
Our safety services will use the information you provide for the sole purpose of identifying and protecting this individual in an emergency or crisis situation. Click here to learn more.
We look forward to partnering with you on this effort. Thank you.
Please describe the individual.
For example, scars, tattoos or birthmarks.
The following information can help our safety personnel better respond during a crisis. Please be specific.
Please provide any additional information that you believe will allow safety personnel to better help this individual in an emergency.
Upload a current photo that only has the person you are submitting for in the picture.
I hereby give my permission for any first responder agency (including but not limited to police, fire/rescue/EMS/911 dispatch center, search and rescue personnel) to retain and distribute the information contained in this registration form to other first responder personnel for the sole purpose of identification and protection of the person identified above in an emergency or crisis situation. By typing your name in the box, you are agreeing to the release terms stated above.
This field is not part of the form submission.
* indicates a required field