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North Miami Police Department Autism Outreach Program

  1. Autism Spectrum Disorder Participant's Information
  2. If applicable 

  3. Vehicle Information
  4. Other Relevant Medical Conditions*
  5. Emergency Contact - Parent, Guardian, Head of Household, Care Provider
  6. Alternative Emergency Contact - Parent, Guardian, Head of Household, Care Provider
  7. (Toys, Music, Objects, Topics, Etc.) 

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

  9. If verbal: Preferred words, sounds, songs, phrases 

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

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

  12. 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.

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  14. This field is not part of the form submission.