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2. Project Safeguard

   Project Safeguard is a project in partnership with the community and local Law Enforcement. This online program promotes communication and gives police quick access to important information about a person who displays a tendency to wander; such as Autism, Dementia or other disability with similar tendencies. This program provides information that is critical for law enforcement prior to an officer's arrival at a scene and/or prior to contacting an individual with disabilities. Rapid access to information such as their name, birthday, physical description, emergency contact information, known triggers and behaviors etc. will help Officers during their initial response. Please share all information you feel comfortable providing. This form should be filled out yearly to insure accurate information is available

6. PERSON COMPLETING THIS FORM
8. First Name*
9. Last Name*
11. Phone Number*
13. Email Address*
15. Relationship to Person with Disability*
17. PERSON WITH DISABILITY INFORMATION
19. Submission Type*

    Mark if this is a New Entry or Renewal

    1. New Enrty
    2. Renewal
21. First Name*
22. Last Name*
24. Race*
26. Gender*

    1. Female
    2. Male
28. Date of Birth*
    Date of Birth
30. Height*
32. Weight*
34. Hair Color*
36. Eye Color*
38. Identifying Features *

    Scars, Birthmarks, Tattoos, other identifying features

40. Files Attached*

    Only attach photographs that have the named person in them

42. DISABILITY INFORMATION
44. Primary Diagnosis*
46. Co-Existing Diagnosis*

    Mark NA if not applicable

48. Communication Method*

    1. Verbal
    2. Non-Verbal
50. Describe if Non-Verbal*

    Mark NA if not applicable

52. Will they respond to their name being called*

    1. Yes
    2. No
54. AUTISTIC CHARACTERISTICS

    Complete this section if person with disability is Autistic

56. Sensory Issues

    1. Seekers
    2. Sensory Avoidance
58. Touch

    1. Seekers
    2. Sensory Avoidance
60. Sounds

    1. Seekers
    2. Sensory Avoidance
62. Bright Lights

    1. Seekers
    2. Sensory Avoidance
64. Stimming Behavior*

    Mark NA if not applicable

66. DISABILITY CHARACTERISTICS
68. Process Delays*

    1. Yes
    2. No
70. Fears*

    Mark NA if not applicable

72. Dislikes/Triggers*

    Mark NA if not applicable

74. Favorite Objects/Topics*
76. Pre-Meltdown Signs*

    Mark NA if not applicable

78. Calming Strategies That Work*

    Mark NA if not applicable

80. Prior Contact with Police*

    Mark NA if not applicable

82. Alcohol/Drug Issues*

    1. Yes
    2. No
84. Does the Family Have a Crisis Plan *

    1. Yes
    2. No
86. WANDERING
88. Prior Wandering Incident *

    1. Yes
    2. No
90. If Prone to Wandering, Where Have They Been Found

    Mark NA if not applicable

92. Closest Water to Residence*

    Mark NA if not applicable

94. List ALL Lakes, Ponds, Streams, Pools, Etc.*

    Mark NA if not applicable

96. Favorite Hiding Places at Home*

    Mark NA if not applicable

98. Favorite Hiding Places in Neighborhood/Community*

    Mark NA if not applicable

100. SCHOOL INFORMATION
102. School Name*

     Mark NA if not applicable

104. Grade*

     Mark NA if not applicable

106. School Address*

     Mark NA if not applicable

108. School Contact Name*

     Mark NA if not applicable

110. School Contact Phone*

     Mark NA if not applicable

112. Bus Use*

     1. School Bus
     2. UTA Bus
     3. Other
114. RESIDENCE INFORMATION
116. Home Address*
118. City*
119. State*
120. Zip Code*
122. Phone Number
124. Weapons in the Home*

     1. Yes
     2. No
126. Weapons Properly Secured *

     1. Yes
     2. No
     3. Not Applicable
128. PRIMARY GUARDIAN/CARETAKER INFORMATION
130. First Name*
131. Last Name*
133. Relationship*
135. Primary Phone*
137. Secondary Phone*

     Mark NA if not applicable

139. Place of Work*

     Mark NA if not applicable

141. Work Address*

     Mark NA if not applicable

143. SECONDARY GUARDIAN / CARETAKER INFORMATION
145. First Name
146. Last Name
148. Relationship
150. Primary Phone
152. Secondary Phone

     Mark NA if not applicable

154. Place of Work

     Mark NA if not applicable

156. Work Address

     Mark NA if not applicable

158. PRIMARY EMERGENCY CONTACT INFORMATION

     Other than previously identified Guardians

160. First Name*
161. Last Name*
163. Relationship*
165. Primary Phone*
167. Secondary Phone *

     Mark NA if not applicable

169. Address*
171. City*
172. State*
173. Zip Code*
177. VEHICLE INFORMATION
179. Vehicle 1 Make
180. Vehicle 1 Model
182. Vehicle 1 Year
184. Vehicle 2 Make
185. Vehicle 2 Model
187. Vehicle 2 Year
189. Add any additional information
193. RELEASE OF INFORMATION
195. I, hereby give my permission for any first responder agency (including but not limited to police, fire/rescue/EMS/911 dispatch center, search and rescue personnel) to retain and distribute the information contained in this registration form to other first responder personnel for the sole purpose of identification and protection of the person identified above in an emergency or crisis situation.
197. By clicking the Release of Information box and typing your full name in the box below, you are agreeing to the release terms posted above.*

     1. RELEASE OF INFORMATION
199. Sign your Full Name*
201. Date*
     Date
Leave This Blank:


203. 1. Receive an email copy of this form.
204. Email address

     This field is not part of the form submission.

205. Submit

* indicates a required field