Special Needs Safety Alert Name(Required) First Date Of Birth(Required) MM slash DD slash YYYY Sex(Required)Eye Color(Required)Hair Color(Required)Scars/ Identifying MarksAddress(Required) Street Address City State / Province / Region ZIP / Postal Code Type Of Condition(Required)Check all that apply. Alzheimer's Dementia Autism Other Other Type Of Condition(Required)Communication(Required)Check all that apply. Verbal Non-Verbal ASL Can Write Will repeat Questions Can answer yes/no questions Can read Sensitive To(Required)Check all that apply. Noise Light Touch Crowds Other Other Sensitive To(Required)Avoidance/ Dislikes(Required)Check all that apply. Eye Contact Being Wet Being Dirty Strangers Men Women Other Other Avoidance/ Dislikes(Required)Calming Methods(Required)Check all that apply. Calm/ Quiet Voice Noise Canceling Headphones Time Alone Food/ Candy Soft Items Other Other Calming Methods(Required)Atypical Behaviors(Required)Check all that apply. Speaks Loudly Self-Injury Will Run if Chased Vocal Stimming High Pitched Noise Little/ No Sense Danger Sensory Seeking Other Other Atypical Behaviors(Required)Medical(Required)Check all that apply. Hearing Impaired Vision Impaired Seizures Tics High Pain Tolerance Other Other Medical(Required)Additional Notes/ Special Instructions:CAPTCHA
