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2. SECTION 1: INFORMATION ABOUT THE PERSON WITH DISABILITY
4. First Name*
5. Last Name*
7. Date of Birth*
   Date of Birth
8. Race*
   -- Select One --AsianBlackNative AmericanPacific IslanderOtherWhite
9. Gender*
11. Height*
12. Weight*
13. Hair Color*
14. Eye Color*
16. Identifying Features (Scars/ Birthmarks/ Tattoos)
18. Primary Language *
20. SECTION 2: RESIDENTIAL INFORMATION
22. Address1*
24. Address2
26. City*
27. State*
28. Zip*
30. Primary Telephone Number*
31. Secondary Telephone Number
33. SECTION 3: DISABILITY INFORMATION
35. Primary Diagnosis*
36. Co-Existing Diagnosis
38. Additional Notes
40. Medication(s)
41. Doctor Information
43. Characteristics*

    Please list any characteristics that are associated with this person: (Examples include sensory issues, certain behaviors, physical aggression, calming strategies, trigger mechanisms, audio or visual aids, or previous dealings with police.)

45. Communications Preferences *

    What is the best method of communication with this individual? (Examples include words, pictures, electronic devices, etc.)

47. SECTION 4: ADDITIONAL CONTACT INFORMATION
49. First Name
50. Last Name
52. Telephone Number
53. Relationship to Disabled Person
55. SECTION 5: PARENT/ GUARDIAN INFORMATION
57. First Name
58. Last Name
60. Primary Telephone Number
61. Secondary Telephone Number
63. Email Address
65. Supporting Documentation

    Person with Disability Supporting Documentation:

    a. Confirmation of a disability or condition and it must be certified by a licensed physician or licensed physician assistant or a licensed advanced practice registered nurse; and /or

    b. Confirmation of a psychological condition and it must be certified by a licensed psychologist, licensed mental health counselor, or a psychiatrist.

    c. A facial photograph in portrait orientation.

    Parent/ Guardian Supporting Documentation:

    a. A birth certificate as described in FS. 382.013;

    b. A power of attorney, as defined in FS. 709.2102(9);

    c. A court order establishing parental rights or guardianship; or

    d. Letters of guardianship as described in FS. 744.345. 

67. File Upload*
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69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field