Special Needs Form

Date:

Name of Special Needs Person:

Nickname:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Other:

Date of Birth:

Height:

Weight:

Eye Color:

Hair Color:

Scars or Identifying Marks:

Medical Conditions:

Method of communication, if non-verbal: sign language, picture boards, written word, etc.:

Identification worn: ex: jewelry/Media Alert®, clothing tags, ID card, tracking monitor, etc.:

Current prescriptions (include dosage):

Sensory, medical, or dietary issues and requirements, if any:

Inclination for wandering behaviors or characteristics that may attract attention:

Favorite attractions and locations where person may be found if missing:

Likes and dislikes (include approach and de-escalation techniques):

Emergency Contact 1 Name:

Emergency Contact 1 Phone:

Emergency Contact 1 Address:

Emergency Contact 1 City:

Emergency Contact 1 State:

Emergency Contact 1 Zip:

Emergency Contact 1 Email:

Emergency Contact 2 Name:

Emergency Contact 2 Phone:

Emergency Contact 2 Address:

Emergency Contact 2 City:

Emergency Contact 2 State:

Emergency Contact 2 Zip:

Emergency Contact 2 Email:

Other Important Information:

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