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2. Special Needs Person Information
4. First Name*
5. Last Name*
6. Nickname(s)
7. Date of Birth*
9. Address*
10. Cell Phone #*
12. City*
13. State*
    -- Select One --NJ - New JerseyAK - AlaskaAL - AlabamaAR - ArkansasAZ - ArizonaCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiIA - IowaID - IdahoIL - IllinoisIN - IndianaKS - KansasKY - KentuckyLA - LouisianaMA - MassachusettsMD - MarylandME - MaineMI - MichiganMN - MinnesotaMO - MissouriMS - MississippiMT - MontanaNC - North CarolinaND - North DakotaNE - NebraskaNH - New HampshireNM - New MexicoNV - NevadaNY - New YorkOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVA - VirginiaVT - VermontWA - WashingtonWI - WisconsinWV - West VirginiaWY - WyomingOther - Non US
14. Zip Code*
16. Height - Feet*
    -- Select One --123456
17. Height - Inches*
    -- Select One --01234567891011
18. Weight (pounds)*
20. Gender*
    -- Select One --FemaleMaleOther
21. Eye Color*
    -- Select One --BlueBrownGrayGreenHazelRed Other
22. Hair Color*
    -- Select One --BrownBlondBlackGrayRedBaldOther
24. Nature of Special Needs*
26. Scars or Identifying Marks
28. Method of communication, if non-verbal: sign language, picture boards, written word, assistive technology, etc.
30. Identification worn: ex: jewelry/Media Alert®, clothing tags, ID card, tracking monitor, etc.
32. Sensory or medical issues and requirements, if any
34. Inclination for wandering behaviors or characteristics that may attract attention
36. Favorite attractions and locations where person may be found if missing
38. Likes and dislikes (include approach and de-escalation techniques)
42. Parent / Legal Guardian Information
44. Guardian 1 Name*
45. Guardian 1 Cell #*
46. Guardian 1 Email*
47. Guardian 1 Relationship*
    -- Select One --MotherFatherGrandparentAunt/UncleLegal GuardianSiblingOther
49. Guardian 2 Name
50. Guardian 2 Cell #
51. Guardian 2 Email
52. Guardian 2 Relationship
    -- Select One --MotherFatherGrandparentAunt/UncleLegal GuardianSiblingOther
56. Miscellaneous Information
58. Any additional information
60. Attach Photo 1 (optional)
61. Attach Photo 2 (optional)
62. Attach Photo 3 (optional)
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64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

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