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2. Autism Spectrum Disorder Participant's Information
4. Last Name, First Name *
5. Preferred Name or Nickname
7. Date of Birth (MM/DD/YYYY)*
9. Home Address *
10. City*
11. State*
12. Zip Code*
14. Does the Individual live alone? *
    -- Select One --Yes No
15. School

    If applicable 

17. Phone Number*
18. Social Media Usernames
20. Email Address
22. Gender *
23. Race*
24. Height *
25. Weight *
27. Eye Color *
28. Hair Color *
29. Scars, Marks, Tattoos, Piercings
31. Photo
33. Work Address
35. City
36. State
37. Zip Code
39. Work Phone Number
43. Vehicle Information
45. Make
46. Model
48. Tag
49. Color
50. Stickers, Decals, Damage, Etc.
54. Other Relevant Medical Conditions*

    1. No Sense of Danger
    2. Sight and/or Sound Sensitive
    3. Blind
    4. Deaf
    5. Non-Verbal
    6. Intellectual Disability
    7. Cognitive Impairment
    8. Prone to Seizures
    9. N/A
56. If Other, Please Explain
58. Prescription Medication Needed
60. Sensory or Dietary Issues
64. Emergency Contact - Parent, Guardian, Head of Household, Care Provider
66. Name*
67. Relationship to Individual
69. Address*
71. City*
72. State*
73. Zip Code*
75. Primary Phone Number*
76. Secondary Phone Number
78. Email Address
80. Alternative Emergency Contact - Parent, Guardian, Head of Household, Care Provider
82. Name
83. Relationship to Individual
85. Address
87. City
88. State
89. Zip Code
91. Primary Phone Number
92. Secondary Phone Number
94. Email Address
98. Favorite Locations or Attractions Where The Individual May Be Found
100. Individual Likes/Dislikes

     (Toys, Music, Objects, Topics, Etc.) 

102. Method of Preferred Communication

     If non-verbal: Sign language, picture boards, written words, etc

104. Method of Preferred Communication

     If verbal: Preferred words, sounds, songs, phrases 

106. Identification Information

     Does the individual carry an identification card, wear jewelry tags, medical alert bracelet, etc? If so, list above. 

108. Tracking Information

     Does the individual have a Project Lifesaver or Lojack SafetyNet transmitter number? 

110. Atypical behaviors or characteristics of the individual that may attract the attention of first responders
112. Additional information for first responders
116. Autism Decal *
     -- Select One --Yes No

     Would you like to receive a decal to display on your residence window or door, to alert North Miami officers that someone in the home has Autism? 

120. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
122. Electronic Signature
Leave This Blank:


124. 1. Receive an email copy of this form.
125. Email address

     This field is not part of the form submission.

126. Submit

* indicates a required field