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2. 

4. This voluntary community registry is intended for people with Autism Spectrum Disorders (ASD) and is a Wilton Manors Police Department project in partnership with the City of Wilton Manors. The registry promotes communication and gives police quick access to critical information about a registered person with autism in a police emergency by capturing information such as a full description, routine/favorite attractions, communication and other special needs as well as emergency contact information. To be truly effective, this form will require your permission to be shared with this jurisdictional law enforcement agency, which your child/dependent adult resides or is in on a regular basis. (i,e., for school, daycare, etc.). The information will be kept confidential and made available only to our patrol officers. **NOTE - A recent Photo will be required to be included with this application.

6. This form can also be printed by clicking this link.
   Printable Form link

8. Currently, individual registration is intended for those with Autism Spectrum Disorders (ASD); although, the registry has been developed with the intent to be expanded for all residents where communication is ineffective when interacting with police. This expansion will be considered upon completion of a formalized evaluation.

12. INDIVIDUAL / PERSON OF CONCERN
13. * Indicates a Required Field
15. Individual's Name*
16. Preferred Name or Nickname
17. Date of Birth*
    Date of Birth
19. Individual's Address (Street, Apt, City, State, Zip)*
20. Lives Alone (Y or N)*
21. Gender*
23. Race*

    1. American Indian/Alaska Native
    2. Asian
    3. Black/African American
    4. Hawaiian/Pacific Islander
    5. Hispanic/Latino
    6. White
24. Height*
25. Weight*
27. Scars / Marks / Tattoos or any physical identifiers?
28. Upload a Recent Photo of Individual*
30. Relevant Medical Conditions in addition to Autism

    1. No sense of Danger
    2. Blind

    1. Deaf
    2. Non-Verbal

    1. Intellectual Disability
    2. Prone to Seizures

    1. Cognitive Impairment
    2. Other
32. If Other, Please Explain
34. Prescription Medications Needed
36. Sensory or Dietary Concerns
38. Additional Information First Responders May Need to Know
42. INFORMATION SPECIFIC TO THE INDIVIDUAL
44. Favorite attraction or location where individual may be found
46. Atypical behaviors or characteristics of the Individual that may attract the attention of Responders
48. Favorite toys, objects, music, discussion topics, likes, or dislikes
50. NON-VERBAL Communication preference: Sign language, picture boards, written words, etc.
51. VERBAL Communication preference: Words, sounds, songs, phrases they respond to, etc.
53. Identification: Carry or wear jewelry, tags, ID card, medical alert bracelets, etc.
55. Tracking Information: Project Lifesaver, LoJack, SafetyNet, etc. (Transmitter Information & Number)
57. Individual may react negatively if...
59. Additional Notes or Information
63. EMERGENCY CONTACT INFORMATION
65. Primary / Emergency Contact Name*
66. Primary / Emergency Contact Address (Street, Apt, City, State, Zip)*
68. Mobile Phone*
69. Home Phone
70. Work Phone
71. Primary Contact Email
73. Alternate Contact Name
74. Alternate Contact Address (Street, Apt, City, State, Zip)
76. Alternate Mobile Phone
77. Alternate Home Phone
78. Alternate Work Phone
79. Alternate Contact Email
83. The person filling out this form is the:*

    1. Individual/Self registrant

    1. Primary Emergency Contact

    1. Alternate Emergency Contact

    1. Other Person/Provider

    **If Other, Please provide additional contact information below.
85. Person / Provider Name
86. Contact Number
87. Email Address
89. * I understand this is a voluntary registry program, and I attest the information provided herein is truthful and accurate. I understand if any information changes or if the registrant no longer resides in the City of Wilton Manors I shall contact the Wilton Manors Police Department without delay and notify them. Furthermore, I understand this registration is valid for one (1) year and I must re-register annually to remain in this program. *

    1. I Agree
Leave This Blank:


91. 1. Receive an email copy of this form.
92. Email address

    This field is not part of the form submission.

93. Submit Submit and Print

* indicates a required field