Special Needs Form

Name of Your Loved One *

What Is the Address Where Your Loved One Spends the Majority of Their Time (City/State/Zip) *

Does Your Loved One Go By a Nick Name? If So, What? *

Date of Birth of the Registered Person *

Diagnosis of the Registered Person *

List All Pertinent Names and Phone Numbers Officers May Need When Dealing With Your Loved One *

Physical Description of the Registered Person (Gender, Weight, Height, Race, Hair, Eyes, Glasses) *

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.) *

Has Your Loved One Ever Ran Away or Been Reported as Missing? *

Yes
No

If So, Where Was He/She Found? *

Is the Registered Person Verbal or Non-Verbal? Please Explain In Detail. *

Does the Registered Person Fear Police or Fire-Ems Personnel or Emergency Vehicles? Explain in Detail. *

Name of Care Givers, Parents, Grandparents or Other Family Members Involved in Your Loved One’s Life *

If Your Loved One Becomes Confrontational, How Could Officers or Rescue Personnel Calm Them Without Your Presence?

Are You Willing to Allow the Hemet Police Department to Place Your Address and the Information of Your Loved One’s Needs Into the System to Insure That Officers Are Better Prepared to Handle the Situation? *

Yes
No

Address *

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 *

Does Your Loved One Have Any Triggers i.e. Lights, Sirens, Loud Radio Noise? Please Explain. *

Does Your Loved One Have Any Other Medical Condition That We Should Be Aware of i.e. Atlantoaxial Subluxation (AAI)? Please Explain. *

Photo *

Click or drag a file to this area to upload.

Your Name *

First

Last

Email *

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