Name of Your Loved One
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Does Your Loved One Go By a Nick Name? If So, What?
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Date of Birth of the Registered Person
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Diagnosis of the Registered Person
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List All Pertinent Names and Phone Numbers Officers May Need When Dealing With Your Loved One
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Physical Description of the Registered Person (Gender, Weight, Height, Race, Hair, Eyes, Glasses)
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Is There a Special Interest (Outside of Their Residence) That Your Loved One Is Drawn To? (For Example: Trains, Water, Woods, Parks, Malls, Traffic, Etc.)
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If So, Where Was He/She Found?
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Is the Registered Person Verbal or Non-Verbal? Please Explain In Detail.
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Does the Registered Person Fear Police or Fire-Ems Personnel or Emergency Vehicles? Explain in Detail.
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Name of Care Givers, Parents, Grandparents or Other Family Members Involved in Your Loved One’s Life
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If Your Loved One Becomes Confrontational, How Could Officers or Rescue Personnel Calm Them Without Your Presence?
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Please Explain in Detail Any Other Important Information That We May Need to Know That Might Assist Us in Not Triggering a Violent Response From Your Loved One
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Does Your Loved One Have Any Triggers i.e. Lights, Sirens, Loud Radio Noise? Please Explain.
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Does Your Loved One Have Any Other Medical Condition That We Should Be Aware of i.e. Atlantoaxial Subluxation (AAI)? Please Explain.
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Your First Name
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Your Last Name
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Email
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If you are human, leave this field blank.
