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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
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
YYYY
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
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
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:
Attach Recent Photo
Click Here to Upload
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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