Special Needs Locator Program

2. Special Needs Person Name/Address
4. First Name
5. Last Name
7. Date of Birth*
8. Gender*
9. Diagnosis*

   Medical diagnosis

11. Address1
13. Address2
15. City
16. State
17. Zip
19. Form Submitter Name/Address
21. First Name
22. Last Name
24. Address1
26. Address2
28. City
29. State
30. Zip
32. General Information
34. Physical Description of Person with Special Needs*

    Be as specific as possible, hair/eye color, race, weight. etc.

36. Family Members*

    List any family members person lives with or is close to.

38. Phone Numbers/Email*

    Please enter phone numbers and emails for anyone that should be contacted regarding this person

40. Is this person tracked by any device/tech*

    1. Yes, if so. Please include how in next option.
    2. No

    EX: LIfe360, iPhone location, etc.

41. Tracking Tech
42. Is this person verbal?*

    1. Yes
    2. No
    3. Occasionally

    If this person speaks other languages other than English, please include in notes section at end of form.

44. Does this person react to their name being called?*

    1. Yes
    2. No
    3. Only with people they are comfortable with
45. Any medication?*

    1. Yes
    2. No

    If the answer is yes and feel comfortable sharing, please add what medication at end of form.

46. Has this person wandered off alone before?*

    1. Yes
    2. No
47. Does this person live with any other special needs persons?*

    1. Yes
    2. No
49. Is this person familiar with the surrounding area around their home/school?*

    1. Yes
    2. No
50. Is this person cautious/familiar with car traffic?*

    1. Yes
    2. No
51. Any favorite places they might head towards when wandering?
53. Is this person familiar with first responders?*

    1. Yes
    2. No

    EX: Police, Fire Department, EMS

54. In general, how does this person act towards Law Enforcement/Police?*
55. How does this person normally respond to touch?*
57. In general, what is this person's fears or any other triggers that may cause a change in behavior?*
58. How does this person respond to pain?*
60. Can this person become upset easily?*

    1. Yes
    2. No
61. If this person upsets easily, what can we do to help?
63. Is this person fascinated by water?*

    1. Yes
    2. No
64. Can this person swim?*

    1. Yes
    2. No
65. Is this person sensitive to light?*

    1. Yes
    2. No

    EX: bright lights, flashing lights, etc.

66. Is this person sensitive to sound?*

    1. Yes
    2. No
68. Please list below any fascinations they have or items they like to be around.

    EX: likes fire trucks, playgrounds, schools, etc.

70. Aggressions?*

    Can this person be aggressive to themselves or others? 

72. This person good with eye contact?*

    1. Yes
    2. No
73. Does this person know their parents' information?*

    1. Yes
    2. No

    EX: where they live, names, phone numbers, etc.

75. Please list below any further information or elaboration on previous questions.
77. Please upload the most recent/best image you have of this person.*

    We prefer .png format.

Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

* indicates a required field