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2. This form is to be used for the purpose of data collection by local law enforcement in order to provide safe community contact to persons with autism and other developmental disabilities.

   The information collected will only be used by local law enforcement and emergency services providers and will not be shared with other organizations or agencies.

   Freehold Township Police Department
   Community Policing Division
   Freehold, NJ 07728
   Phone: 732-294-5143

4. Name of Person with Disability*
5. Parent/Guardian Name
7. Address*
9. City
10. State
11. Zip Code
13. Phone Number
14. Date of Birth of Person with Disability
16. Nickname (If Any)
17. Email*
19. Diagnosis/Disability
20. Emergency Contact Name
22. Emergency Contact Address
24. Emergency Contact Phone
28. Language
30. How does this person communicate? (Verbal or non-verbal? Sign Language?)
31. Is he/she likely to follow simple directions?
33. Is he/she able to provide personal information, if asked?
37. Identification
39. Is his/her name marked in their clothing or listed on an identification card in their pocket?
40. Does he/she carry any identification jewelry (i.e. name bracelet or caduceus pendant)?
42. Does he/she have any identifying marks (i.e. scars, birthmarks or tattoos)?
46. Behavior
48. Is there any unusual or challenging behavior we should be aware of? (Self injurious, self stimulatory, obsessive-compulsive, other. Please explain).
50. Is this person easily agitated? (Please explain.)
52. Is this person likely to become violent? If "yes," under what circumstances?
56. Individual Issues
58. Is he/she likely to wander off? If "yes", where or what is he/she likely to be drawn to? (Favorite place or hobby?)
60. What does he/she like or find calming?
62. Does he/she have any phobias or unusual fears?
64. Are there sensory issues?
66. Are there any other special concerns?
70. Medical
72. What type of medications is he/she presently on? (Please list).
74. Are there any other issues or any information that you would like to bring to our attention?
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field