Autism Spectrum Disorder (Asd) Safety Planning Packet Page 3
ADVERTISEMENT
1
2
3
4(ASD) Emergency Contact Form
Date Submitted: Department of Transportation: ______ School: ________
Autism Spectrum Disorder (ASD) Emergency Contact Form
Attach Photo
Individual’s Name: _____________________________________________________________
(First)
(Middle)
(Last)
Address: _____________________________________________________________
(Street)
(City)
(State)
(Zip)
Date of Birth: ______ Age: _________ Preferred Name (Nickname):____________________
Individual’s Physical Description:
___Male
___Female
Height: _____ Weight: ______ Eye Color: ______ Hair Color: _______
___Scars or Identifying Marks If checked- please note specifics:
_____________________________________________________________________________________________________
Medical Condition: _________________________________________________________________________________
Method of Communication: (if non-verbal: sign language, picture symbols, written words,
etc.)_________________________________________________________________________________________________
_____________________________________________________________________________________________________
Identification on Person: (ex: Jewelry/Medic Alert, clothing tag, ID card, tracking monitor, etc.)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
State of Iowa: ID Number _________________________________________________
Emergency Contact Information:
Name of Primary Emergency Contact: (circle relationship: parent, guardian, head of
household/residence or Care Provider)
Emergency Contact Address: _____________________________________________________________
(Street)
(City)
(State)
(Zip)
Emergency Contact Phone:
Cell: ____________________ Home: _________________________ Work: _____________________________
Other Emergency Contacts-
Medical Care Providers
if Primary Unavailable in in prioritized order
1. Name:________________________________
1. Name:________________________________
Phone:________________________________
Phone:________________________________
2. Name_________________________________
2. Name_________________________________
Phone:________________________________
Phone:________________________________
3. Name: ________________________________
3. Name: ________________________________
Phone:________________________________
Phone:________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business