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Help Me Home Program Registration Form (JPD Form 206)

  1. Jacksonville Public Safety, Help Me Home Program Registration Form
    Jacksonville Department of Public Safety understands the unique nature of Autism and we would like to work together to gather crucial information regarding your loved one in order to ensure the highest levels of customer service are provided. In the event of an emergency, the information you provide will be vital to ensure we are able to properly respond and aid your loved one in their time of need. Please complete the following information:
  2. Upload a current photo here
  3. Is he or she verbal?
  4. Is he or she noise sensitive?
  5. Does he or she self stimulate (stimming)?
  6. Does he or she have seizures?
  7. Is he or she touch sensitive?
  8. Does he or she run from home?
  9. Does he or she have a history of violent behavior?
  10. Does he or she have a history of drug or alcohol abuse?
  11. Parent, Guardian and Custodian Contact Information
    Please fill out completely
  12. Secondary Contact
    Please fill out completely
  13. By typing your name here, you agree to the following: I, the parent, guardian or custodian, of the at risk person listed in this form, give permission to the Jacksonville Department of Public Safety to retain and distribute this information to emergency first responders and law enforcement personnel for the sole purpose of identification and assistance to the person at risk. The parent, guardian or custodian will be responsible for updating information on an annual basis or in the event changes are needed.
  14. Leave This Blank:

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