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Voluntary Disclosure Form

  1. Relationship to individual:*
  2. Individual's condition that prompted you to fill out this form (please select all that apply):*
  3. Gender:*
  4. Glasses?*
  5. Hearing Impaired?*
  6. Does the person have a cell phone?*
  7. Is the individual verbal?*
  8. Does the individual wear / carry any medical identification jewelry / cards?*
  9. Does the individual have access to guns or weapons?*
  10. Is the individual attacted to (check all that apply):*
  11. Does the individual have a project lifesaver or lojack safetynet identification number?*
  12. Select all that apply to this individual*
  13. Has the individual had a prior wandering event?*
  14. Sensory issues / triggers (if applicable - select all that apply):*
  15. Individual avoids (if applicable - select all that apply):*
  16. Atypical Behaviors (if applicable - select all that apply):*
  17. Calming Methods / Preferred Strategies (if applicable - select all that apply):
  18. Calming ways to touch (if applicable - select all that apply):

    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.

  20. Leave This Blank:

  21. This field is not part of the form submission.