Autism Emergency Contact Form

The Lancaster Police Department would like residents with autistic child to complete this form to better serve families.

Name of Child/Adult with Autism

Nickname (if any)

Date of Birth

Height

Weight

Eye Color

Hair Color

Scars or identifying marks

Medical Conditions

Address

Home phone

Other Phone

Method of Communication, if non-verbal: sign language, picture board, written word, etc

Identification Worn: jewelry, Medic Alert, clothing tags, ID card, tracking monitor, etc

Current Prescriptions

Sensory/ Medical/ Dietary issues and requirements, if any

Inclination for wandering behaviors or characteristics that may attract attention

Favorite attractions or locations where the person may be found, if missing

Likes/ Dislikes: include approach and de-escalation techniques

Medical care provider name/phone number

Parent/Caregiver Name/ Phone

Emergency Contact Name/Phone

Additional Information