Orem Police Department Special Needs Form
Name
*
First Name
Last Name
Nick Name(s) / Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Race / Ethnicity
*
Sex
*
Male
Female
Height
*
Weight
*
Eyes
*
Glasses
*
Yes
No
Hairstyle
*
Hair
*
Identifying Features / Marks / Tattoos:
ID Worn: (bracelet, name tag, tracker)
Medical Condition(s):
Current Prescription Medication:
Normally takes medication as directed?
Yes
No
Medication or food allergies:
Communication
*
Please Select
Verbal
Non-verbal
Explain best way to communicate
Cognitive Ability/ IQ
Sensory Issues - Please explain:
Fears or Triggers that may upset individual:
*
Calming methods (favorite topics/interest, music, etc.): *
*
Places of interest they may wander:
*
Are they attracted to water? Please explain.
Topics of interest / Safety Concerns (aggressive, suicidal, assaultive)
*
What would happen if this individual was approached by a Police Officer?
*
Other info:
Attach Recent Photo
*
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Caregiver/Emergency Contact Information
Choose one:
*
Please Select
Parent
Guardian
Friend
Family Member
Third Party Caregiver
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Provider Information
Provider Full Name:
*
First Name
Last Name
Clinic/Practice Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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