Autism Awareness Program Registration

This is a voluntary program. By completing this form you are giving Lake County Sheriff's Office permission to enter the provided information into the Lake County Sheriff's Office dispatch database, for informational purposes only. The provided information will not be shared with any other entity.

Personal Identifying Information:

FIRST NAME:
LAST NAME:
Best Contact Number:
Address:
City:
State:
Zip:
DATE OF BIRTH
Gender:
Race:
Height:
Weight:
Eye Color:
Hair Color:
Any identifying marks or scars?
Do they wear a location device and/or ID bracelet?:
Any other special identifiers?:

Emergency Contacts:

Name:
Relationship:
Phone:
Address:
City:
State:
Zip:
Name:
Relationship:
Phone:
Address:
City:
State:
Zip:

Medical Information:

Medical Needs or Medications:
Allergies or Dietary Restrictions:

Helpful Considerations:

Locations the individual is likely to go:
What do their escalated behaviors look like?
De-escalation techniques (how to stop/slow a behavior):
Best way to approach the individual:
Identify Likes:
Identify dislikes/triggers:
Preferred Communication:
A safe word or any identifier to indicate to the individual that you are a safe person:
Email address will be used for registration confirmation and any follow-up required.
Email: