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2. Madison Heights Autism and Vulnerable Citizen Emergency Contact Form
4. Name (Last, First, Middle)
5. Date of Birth
7. Address, City & Zip
9. Upload Current Photo
11. Medical Diagnosis
13. Gender
14. Race
15. Height
16. Weight
18. Hair Color
19. Eye Color
21. EMERGENCY CONTACT INFORMATION
23. Parent/Guardian Name:
24. Phone Number
26. Parent/Guardian Name:
27. Phone Number
29. School/Employer/Other
30. Staff Contact Name
32. Address, City, State, & Zip code
33. Phone Number
35. Identifying Marks/Scars
37. Allergies
39. Medication
41. Important information for responders—key phrases or items that may help in a situation. i.e. Cannot be left alone
43. Sensory or dietary issues, if any
44. Communication Methods-verbal, Sign Language, Visuals, Software
46. Behaviors that may be exhibited—i.e. runner, eat non-edible items, head butts, etc
48. ADDITIONAL EMERGENCY CONTACT
50. Name
51. Phone Number
52. Relationship
54. Name
55. Phone Number
56. Relationship
58. Name
59. Phone Number
60. Relationship
62. Favorite attractions or locations where they may be found
64. Identification Information (does the individual carry or wear: jewelry, tags, I.D. card, or medical alert bracelet)?
66. Tracking information: Project Lifesaver or Lojack SafetyNet Transmitter
68. Other
70. Name of person completing form
71. Date / Time
    Date / Time

    Date / Time
73. Email Address
74. Signature
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field