Person with Additional Needs

If you have a loved one with a mental or intellectual disability, please input their information here.
This will allow officers to identify your loved one if they are ever lost or if an event happens that separates you from them.
This information will not be released to the public. Only officers with access will be able to see your loved one's information.
Please ensure that your phone number and address are always current.

Your Contact Information

First Name *

Last Name *

E-mail Address *

Phone Number *

Handle with Care Person

First Name *

Last Name *

Date of Birth *

Month

Day

Year

Race(s) *

Gender *

Height *

Weight *

Location

Get Address from Map Marker

Organization / Building / etc

Street Address *

Apartment / Suite Number

City *

State *

Zip Code *

Map Marker

Use Location Address Use My Current Location

Hint, click the map to add or drag a GPS Marker. Zoom in for a better view.

Information

Include school/work info, car info, triggers, calming methods, service animal, etc.

Additional Notes / Condition / Consideration *

Photo

Attach a photo (jpg, jpeg, png) of the person.

Emergency Contacts

Include as much contact information as possible, e.g. name, address, phone, etc.

Emergency Contact #1 *

Additional Emergency Contacts

Agree *

I understand that submitting a false report is punishable by law.

Leave this field blank