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Section 1 of 3 in this document
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Orem Police Department Special Needs Form
Full Name
First Name
*
Last Name
*
Nick Name(s) / Preferred Name
Date of Birth
Month
*
MM
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
DD
01
02
03
04
05
06
07
08
09
10
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12
13
14
15
16
17
18
19
20
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31
Year
*
YYYY
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Race / Ethnicity
*
Sex:
Male
Female
Height
*
Weight
*
Eyes
*
Glasses
Yes
No
Hairstyle
*
Hair
*
Identifying Features / Marks / Tattoos:
ID Worn: (bracelet, name tag, tracker)
Medical Condition(s):
Current Prescription Medication:
Normally takes medication as directed?
Yes
No
Medication or food allergies:
Communication
*
Choose One
Verbal
Non-Verbal
Explain best way to communicate
Cognitive Ability/ IQ
High
Average
Low
Sensory Issues - Please explain
Please explain:
Fears or Triggers that may upset individual:
*
Calming methods (favorite topics/interest, music, etc.):
*
Places of interest they may wander:
*
Are they attracted to water? Please explain.
Topics of interest /Safety Concerns (aggressive, suicidal, assaultive)
*
What would happen if this individual was approached by a Police Officer?
*
Other info:
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Section 2 of 3 in this document
Caregiver/Emergency Contact Information:
Choose One:
Parent
Guardian
Friend
Family Member
Third Party Caregiver
Full Name
First Name
Last Name
Cell Phone Number
Full Address
Street Address
City
State
Zip
Medical Provider Info
Provider Full Name
First Name
Last Name
Clinic/Practice Name:
Office Phone Number
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