Special Needs Alert Form
Glynn County Police Department
General Information for Special Concerns Person
Person-Specific Information for First Responders -- This information will only be used for Public Safety Responses only! Please complete the entire form to be added to our Special Needs database.
Name
*
First Name
Last Name
Nickname (s)
Date of Birth
-
Month
-
Day
Year
Date
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Individuals Physical Description
Biological Gender
Female
Male
Height
Height
Weight
Eye Color
Hair Color
Skin Tone
Scars or other identifying marks:
Prescription Medications Needed:
Relevant Medical conditions and or disabilities:
Blind
Deaf
Learning Disability
Cerebral Palsy
Muscular Dystrophy
Non Verbal
ADHD
Attracted to Water
Prone to Seizures
Cognitive Impairment
Down's Syndrome
Emotional Disturbances
Autism
Dyslexia
Individual has no sense of Danger
Other
Food and other Allergies:
Sensory or Dietary issues:
Calming Methods, and any additional information regarding the individual that would be helpful to first responders:
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Emergency Contact Information
Please list additional points of contact for Special Concerns Person.
Name
First Name
Last Name
Home Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Submit
Should be Empty: