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2. Autism Spectrum Disorder Participant's Information
4. First & Last Name
5. Preferred Name/ Nicknames
7. Date of Birth (MM/DD/YYYY)*
   Date of Birth (MM/DD/YYYY)
9. Address1*
11. City*
12. State*
13. Zip*
15. Does the Individual live alone? *
    -- Select One --YesNo
16. School
18. Phone Number*
19. Social Media Usernames
21. Email Address
23. Gender*
24. Race*
25. Height*
26. Weight*
28. Eye Color*
29. Hair Color*
30. Scars, Marks, Tattoos, Piercings
32. Photo
34. Work Address
36. City
37. State
38. Zip
40. Work Phone Number
44. Vehicle Information
46. Make
47. Model
49. Tag
50. Color
51. Stickers, Decals, Damage, Etc.
55. Other Relevant Medical Conditions*

    1. No Sense of Danger
    2. Sight and/or Sound Sensitive
    3. Blind
    4. Deaf
    5. Non-Verbal
    6. Intellectual Disability
    7. Cognitive Impairment
    8. Prone to Seizures
    9. N/A
57. If Other, Please Explain
59. Prescription Medication Needed
61. Sensory or Dietary Issues
65. Emergency Contact - Parent, Guardian, Head of Household, Care Provider
67. First & Last Name*
68. Relationship to Individual*
70. Address*
72. City*
73. State*
74. Zip*
76. Primary Phone Number*
77. Secondary Phone Number
79. Email Address
81. Alternative Emergency Contact - Parent, Guardian, Head of Household, Care Provider
83. First & Last Name
84. Relationship to Individual
86. Address
88. City
89. State
90. Zip
92. Primary Phone Number
93. Secondary Phone Number
95. Email Address
99. Favorite Locations or Attractions Where The Individual May Be Found
101. Individual Likes/Dislikes

     (Toys, Music, Objects, Topics, Etc.) 

103. Method of Preferred Communication

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

105. Method of Preferred Communication

     If verbal: Preferred words, sounds, songs, phrases 

107. Identification Information

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

109. Tracking Information

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

111. Atypical behaviors or characteristics of the individual that may attract the attention of first responders
113. Additional information for first responders
117. 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.

     1. I agree
119. Electronic Signature
Leave This Blank:


121. 1. Receive an email copy of this form.
122. Email address

     This field is not part of the form submission.

123. Submit

* indicates a required field