Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Project Safeguard

  1. 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

  2. PERSON COMPLETING THIS FORM
  3. PERSON WITH DISABILITY INFORMATION
  4. Submission Type*

    Mark if this is a New Entry or Renewal

  5. Gender*
  6. Scars, Birthmarks, Tattoos, other identifying features

  7. Only attach photographs that have the named person in them

  8. DISABILITY INFORMATION
  9. Mark NA if not applicable

  10. Communication Method*
  11. Mark NA if not applicable

  12. Will they respond to their name being called*
  13. AUTISTIC CHARACTERISTICS

    Complete this section if person with disability is Autistic

  14. Sensory Issues
  15. Touch
  16. Sounds
  17. Bright Lights
  18. Mark NA if not applicable

  19. DISABILITY CHARACTERISTICS
  20. Process Delays*
  21. Mark NA if not applicable

  22. Mark NA if not applicable

  23. Mark NA if not applicable

  24. Mark NA if not applicable

  25. Mark NA if not applicable

  26. Alcohol/Drug Issues*
  27. Does the Family Have a Crisis Plan *
  28. WANDERING
  29. Prior Wandering Incident *
  30. Mark NA if not applicable

  31. Mark NA if not applicable

  32. Mark NA if not applicable

  33. Mark NA if not applicable

  34. Mark NA if not applicable

  35. SCHOOL INFORMATION
  36. Mark NA if not applicable

  37. Mark NA if not applicable

  38. Mark NA if not applicable

  39. Mark NA if not applicable

  40. Mark NA if not applicable

  41. Bus Use*
  42. RESIDENCE INFORMATION
  43. Weapons in the Home*
  44. Weapons Properly Secured *
  45. PRIMARY GUARDIAN/CARETAKER INFORMATION
  46. Mark NA if not applicable

  47. Mark NA if not applicable

  48. Mark NA if not applicable

  49. SECONDARY GUARDIAN / CARETAKER INFORMATION
  50. Mark NA if not applicable

  51. Mark NA if not applicable

  52. Mark NA if not applicable

  53. PRIMARY EMERGENCY CONTACT INFORMATION

    Other than previously identified Guardians

  54. Mark NA if not applicable

  55. VEHICLE INFORMATION
  56. RELEASE OF INFORMATION
  57. 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.
  58. 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.*
  59. Leave This Blank:

  60. This field is not part of the form submission.