Autism Awareness Form

The Clearfield Police Department Autism Awareness Enrollment is intended to help law enforcement, EMS, Fire, and other emergency responders communicate and interact with individuals with autism. This voluntary enrollment form provides critical information for emergency personnel responding to a scene or contacting an individual.

Submitted forms will be entered into the Clearfield Police Department Records Management System and accessible by the Clearfield Dispatch Center. It is recommended that this form be updated yearly so first responders have current information when handling emergency and non-emergency situations.

Is this a new form or an update to a previous one? *

New Entry
Update

Name of person completing this form *

First

Last

Phone number of person completing this form

Email of person completing this form

Relationship to person with autism

Name of person with autism *

First

Last

Race

Biological sex *

Female
Male
Choose not to identify

Date of birth *

Height

Weight

Hair color

Eye color

Upload a current photograph that only has the person you are submitting for in the picture.

Click or drag a file to this area to upload.

Primary diagnosis *

Co-existing diagnosis

Communication method *

Verbal
Non-Verbal

Describe if non-verbal

Will they respond to their name being called? *

Does the individual have sensory sensitivities? *

Yes - Complete following sensory questions.
No

Touch

Seekers
Avoidance

Sounds

Seekers
Avoidance

Bright lights

Seekers
Avoidance

End of sensory sensitivities section.

Stimming behavior

If yes, describe the stimming behavior.

Process delays

List relevant fears

Dislikes and/or triggers

Favorite objects/topics

Pre-meltdown signs

Meltdown behavior

Calming strategies that work

Prior contact with police

Alcohol/drug issues?

Does the family have a crisis plan?

Any prior wandering incidents?

If prone to wandering, where have they been found?

Closest water to residence (list lakes, ponds, streams, pools, etc.)

Favorite hiding places at home

Favorite hiding places in the neighborhood/community

Name of school, or mark N/A

Grade, or mark N/A

School address, or mark N/A

Address Line 1

Address Line 2

City

State

Zip Code

School contact name, or mark N/A

First

Last

School contact phone, or N/A

Bus use

School Bus
UTA
None

Address of individual with autism *

Address Line 1

Address Line 2

City

State

Zip Code

Phone number *

Weapons in the home?

Weapons properly secured?

Name of primary guardian/caretaker

First

Last

Relationship

Primary phone

Secondary phone

Guardian place of work

Guardian work address

Address Line 1

Address Line 2

City

State

Zip Code

Name of secondary guardian/caretaker

First

Last

Relationship

Primary phone

Secondary phone

Secondary guardian place of work

Secondary guardian work address

Address Line 1

Address Line 2

City

State

Zip Code

Vehicle 1 make

Vehicle 1 model

Vehicle 1 year

Vehicle 2 make

Vehicle 2 model

Vehicle 2 year

Emergency contact

First

Last

*Different than previously identified guardians (family friends/others outside household).

Relationship

Primary phone

Secondary phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Any additional information not previously mentioned.

RELEASE OF INFORMATION: I, hereby give my permission for any first responder agency (including but not limited to police, fire, rescue, EMS, 911 dispatch center, search and rescue personnel) to retain the information contained in this registration form to and to share with other first responder personnel for the sole purpose of identification and protection of the person identified above. By clicking the Release of Information box and typing your full name in the box below, you are agreeing to the release terms posted above. *