Autism Elopement Alert Form - Person-Specific Information For First Responders

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AUTISM ELOPEMENT ALERT FORM
Date Submitted:___________________
PERSON-SPECIFIC INFORMATION for FIRST RESPONDERS
Individual’s Name ________________________________________________________ _
(First)
(M.I.)
(Last)
Attach current
photo here
Address:_________________________________________________________________
(Street)
(City)
(State)
(Zip)
Date of Birth ____________________ Age______ Preferred Name ________________
Does the Individual live alone? ___________
Individual’s Physical Description:
___Male
___Female
Height: ________
Weight: ________
Eye color: ________
Hair color: ________
Scars or other identifying marks:________________________________________________________________
Other Relevant Medical Conditions in addition to Autism
:
(check all that apply)
___No Sense of Danger
___Blind
___Deaf
___Non-Verbal
___Mental Retardation
___Prone to Seizures
___Cognitive Impairment
___Other
___Attracted to Water
If Other, Please explain: ________________________________________________________________
_______________________________________________________________________________________
Prescription Medications needed:
_______________________________________________________________________________________
_______________________________________________________________________________________
Sensory or dietary issues, if any:
_______________________________________________________________________________________
_______________________________________________________________________________________
Calming methods, and any additional information First Resonders may need:
_______________________________________________________________________________________
_______________________________________________________________________________________
EMERGENCY CONTACT INFORMATION
Name of Emergency Contact (Parents/Guardians, Head of Household/Residence, or Care Providers):
_______________________________________________________________________________________
Emergency Contact’s Address:_______________________________________________________________
(Street)
(City)
(State)
(Zip)
Emergency Contact’s Phone Numbers:
Home: __________________
Work: ____________________ Cell Phone: _____________________
Name of Alternative Emergency Contact: _____________________________________________________
Home: __________________
Work: ____________________ Cell Phone: _____________________
Information Speci c to the Individual continued on next page.
FRAF_page 1

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