Fillable Special Needs Individual Information Form (All Cognitive Disorders) (City of Lighthouse Point)

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Special Needs Individual Information Form (All Cognitive Disorders) (City of Lighthouse Point)

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The Special Needs Individual Information Form (All Cognitive Disorders) (City of Lighthouse Point) form is 3 pages long and contains:

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Lighthouse Police Department
Special Needs Individual
Information Form
(All Cognitive Disorders)
1 | Page
Special Needs Individual’s Name:
Individual’s preferred name or nickname:
DOB:
Age:
Individual’s Place of Residence:
(Number and Street):
(City, State, Zip Code):
Business/Condo/Apartment Complex Name:
Individual’s Cell Phone Number:
PHYSICAL DESCRIPTION OF INDIVIDUAL
Approximate Height and Weight are acceptable.
PHOTOGRAPH OF INDIVIDUAL
The attached photograph should depict the individual from the
shoulders up, like a school yearbook photograph.
Gender:
Race:
Hair Color:
Eye Color:
Approximate Height:
Approximate Weight:
In the space provided below, please
describe any Scars, Marks, Tattoos, etc.
that may be helpful in identifying the
special needs individual.
Select Gender
Select Race
Select Hair Color
Select Eye Color
Lighthouse Police Department
Special Needs Individual
Information Form
(All Cognitive Disorders)
2 | Page
EMERGENCY CONTACT PERSON FOR SPECIAL NEEDS INDIVIDUAL
Name:
Address:
Telephone Number: Additional Telephone Number:
Email Address:
ALTERNATE EMERGENCY CONTACT PERSON FOR SPECIAL NEEDS INDIVIDUAL
Name:
Address:
Telephone Number: Additional Telephone Number:
Email Address:
Click or tap here to enter text.
PLEASE LIST ALL COGNITIVE DISORDERS (NEUROCOGNITIVE AND/OR DEVELOPMENTAL)
Disorder Name
Diagnosed by a
Physician?
Physician’s Name and Telephone Number
1.
Name:
#
2.
Name:
#
3.
Name:
#
4.
Name:
#
5.
Name:
#
6.
Name:
#
Physicians will only be contacted during an emergency, and only for information critical to an active investigation.
OTHER NOTEWORTHY MEDICAL CONDITIONS (DIAGNOSIS AND/OR BRIEF DESCRIPTION)
This section should include other conditions such as; no sense of danger, blind or vision issues, deaf or hearing issues, nonverbal
communicator, mental retardation, prone to seizures, other cognitive impairment.
SPECIAL NEEDS SPECIFIC INFORMATION
Please list favorite local attractions or locations where the individual may go.
Lighthouse Police Department
Special Needs Individual
Information Form
(All Cognitive Disorders)
3 | Page
Please list favorite attractions or locations where individual may travel to.
External stimuli that may attract the individual.
Favorite toys, objects, music, discussion topics, likes or dislikes.
Preferred method of communication. (Preferred words or phrases, sounds, songs, gestures, etc.
Identifying Information. (jewelry, special tags, ID card, medical alert bracelets, etc.)
Tracking device. (Project Lifesaver, LoJack Safety Net Transmitter Number, or similar technology)
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Special Needs Individual Information Form (All Cognitive Disorders) (City of Lighthouse Point)

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Completed 17 August 2021

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