Farmington Police Department

Information Sheet for the Individual with Autism for Police and Emergency Response Agencies
Due to the unique nature of this disability it is stressed for parents and their local emergency response
agencies to work together so that crucial information about the individual is available in the case of an emergency.

Last Name:	____________________	First Name:	__________________________________
Birth Date:	____________________	Race:	__________________________________
Sex:	____________________	Height:	__________________________________
Weight:	____________________	Hair Color:	__________________________________
Eye Color:	____________________
		Other	__________________________________
Current photo available?:	YES NO	Features:	__________________________________

Mental Health Diagnosis	_________________________________________________________
Medical Concerns	_________________________________________________________
	_________________________________________________________
Medical Allergies	_________________________________________________________
	_________________________________________________________

Does he/she have Seizures	YES         NO
Is he/she noise sensitive	YES         NO
Does he/she self-stimulate	YES         NO
If he/she runs away, where is she likely to go?
Alcohol/Drug issues?	YES          NO

Is he/she Verbal	YES          NO
Is he/she touch sensitive	YES          NO
Does he/she run from home or school?	YES          NO
History of violence	YES          NO

Any fears, anxieties or triggers which upset him or her?  If so what? ___________________________________________________________________________________

Does he/she have a special interest in any topic, object or theme? ____________________________________________________________________________________

Any other pertinent information: ________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Release

I, ______________________________________, give my permission to the town of Farmington to retain and distribute this information to first response and law enforcement personnel for the sole purpose of identification and assistance to the person at risk.

Print Name	______________________________________
Signature	______________________________________
Date	______________________________________

For more information on Autism, contact the Autism Society of Maine, 1-800-273-5200.  They can arrange to train your police department.  If assistance is needed after hours, contact US Probation Officer Matt Brown by pager, 758-5001.

CONTACT INFORMATION

Name of Parent or Guardian: _____________________________________________

Address of contact person: _______________________________________________

Phone numbers for contacts: ______________________________________________

_____________________________________________________________________

_____________________________________________________________________

Current Photo