Name * Nickname Address Home Telephone Number Cell Phone Number Birthdate Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Race/Nationality White Black Hispanic Asian/Pacific Islander Gender Male Female Height Weight Hair Color Eye Color Employer/School Address Special Concern or condition Medications How does this medication affect actions, responses, senses, the potential for violence, etc? Please list any activations or triggers which may escalate an encounter? What actions should be avoided, if possible, by first responders? Suggestions and tecniques that can be taken to resolve a confrontation successfully: Please answer Yes or No - This person is: Sensitive to light Yes No Likely to hide Yes No Sensitive to touch Yes No Subject to seizures Yes No Afraid of police/uniformed people Yes No Violent Yes No Other Responsible party completing this form Responsible Party Name * Relationship * Home address * Home telephone No. Cell phone number * Signature * Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Emergency contact information Name * Relationship * Address * Home telephone No. Cell phone number * Leave this field blank
