Voluntary Disclosure

2. First Name of reporter:*
3. Last Name of reporter:*
5. Address:
7. City:
8. State:
9. Zip Code:
11. Phone Number:*
12. Email Address:
14. First Name of Individual:*
15. Last Name of Individual:*
17. Preferred Name (if different from given name):
18. Photograph of the individual:
20. Relationship to individual:*

    1. Father
    2. Mother
    3. Spouse
    4. Sibling
    5. Legal Guardian
    6. Other
21. If other, please describe:
23. Individual's condition that prompted you to fill out this form (please select all that apply):*

    1. Autism Spectrum Disorder (ASD)
    2. Down Syndrome
    3. Alzheimers
    4. Dementia
    5. Bipolar Disorder
    6. Schizophernia
    7. Prior Suicidal Incident(s)
    8. Severe Anxiety / Depression
    9. Other:
24. If other was selected, please describe what condition
26. Gender:*

    1. Male
    2. Female
    3. Other
28. Address:*
30. City:*
31. State:*
32. Zip Code:*
34. Birthdate of Individual*
    Birthdate of Individual
36. Height:*
37. Weight:*
38. Hair Color:
39. Eye Color:*
41. Glasses?*

    1. Yes
    2. No
    3. Other
42. Hearing Impaired?*

    1. Yes - Deaf without hearing aides
    2. Yes - Uses hearing aides
    3. No
    4. Other
44. Does the person have a cell phone?*

    1. Yes
    2. No
45. If yes, please provide cell phone number and carrier:
47. Scars, tattoos, or any other identifying marks? (If applicable - be specific):
49. Is the individual verbal?*

    1. Yes - Individual can communicate verbally with others
    2. No - Individual uses technology to communicate (iPad, Etc.)
    3. No - Individual cannot speak and does not use communication
    4. Other:
50. If other, please describe:
52. Does the individual wear / carry any medical identification jewelry / cards?*

    1. Yes
    2. No
    3. Other
53. If other, please describe:
55. Does the individual have access to guns or weapons?*

    1. Yes
    2. No
    3. Other:
56. If other, please describe:
58. Is the individual attacted to (check all that apply):*

    1. Bodies of water / swimming pools
    2. Highways
    3. Train Tracks
    4. Wooded Areas
    5. None Known
    6. Other:
59. If other, please describe:
61. Does the individual have a project lifesaver or lojack safetynet identification number?*

    1. Yes - Project Lifesaver
    2. Yes - Lojack Safetynet
    3. No
    4. Other:
62. If Project Lifesaver, Lojack Safteynet, or Other, please provide ID#:
64. Select all that apply to this individual*

    1. Vision Impaired
    2. Hearing Impaired
    3. Wears Diapers / Pull-Ups
    4. Prone to Seizures
    5. High Pain Tolerance
    6. PICA (puts non-food items in mouth)
    7. Feeding Tube
    8. None Known
    9. Other:
65. If other, please describe:
67. Has the individual had a prior wandering event?*

    1. Yes
    2. No
    3. Other:
68. If other, please describe:
70. If you answered Yes to the previous question, where was the individual found?
71. Favorite hiding place at home (if applicable):
73. Sensory issues / triggers (if applicable - select all that apply):*

    1. Noise
    2. Light
    3. Touch
    4. Crowds
    5. None Known
    6. Other:
74. If other, please describe:
76. Individual avoids (if applicable - select all that apply):*

    1. Eye Contact
    2. Being Wet
    3. Being Dirty
    4. Strangers
    5. Wearing Shoes / Clothes
    6. No Known Avoidances
    7. Other:
77. If other, please describe:
79. Atypical Behaviors (if applicable - select all that apply):*

    1. Makes Vocal Stimming / High Pitch Noises
    2. Will Run if Approached
    3. Speaks Loudly but not Aggressive
    4. Does not Show Emotion
    5. Self Injury Behavior
    6. Sensory Seeking (Crashes into things)
    7. Little or No Sense of Danger
    8. Difficulty Recognizing Faces - Even Relatives / Friends
    9. No Known Atypical Behaviors
    10. Other:
80. If other, please describe:
82. If applicable, please elaborate on any atypical behaviors you selected in the previous question:
84. Calming Methods / Preferred Strategies (if applicable - select all that apply):

    1. Noise Blocking Headphones
    2. Candy
    3. Calm / Quiet Voices
    4. Time Alone
    5. Music
    6. Other:
85. If other, please describe:
87. Calming ways to touch (if applicable - select all that apply):

    1. Hugs
    2. High Fives
    3. Hold Hands
    4. Fist Bumps
    5. Other:
88. If other, please describe:
90. Individuals favorite topics to talk about (people, places, foods, cartoon charcters, sports, movies, video games, etc.):
92. AUTHORIZATION FOR RELEASE OF INFORMATION:*

    1. Yes
    2. No

    I hereby give my permission to the OLMSTED TOWNSHIP POLICE DEPARTMENT and its employees to retain and distribute the attached photo and the information contained in this form to other first responder personnel, or media outlets for the sole purpose of identification and protection of the persons identified above in an emergency or crisis situation. 

    By CLICKING "YES", you are signing the release of information AND you are agreeing to the release terms posted above.

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94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit

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