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2. 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:
4. First Name*
5. Last Name*
7. Prefers to be addressed as
8. Date of Birth*
   Date of Birth
9. Photo
   Upload a current photo here
11. Race
12. Gender*
13. Height*
14. Weight*
16. Hair Color*
17. Eye Color*
18. Wears Glasses
20. Distinguishing Features
22. Mental Health Diagnosis
24. Medical Concerns
26. Allergies
28. Is he or she verbal?

    1. Yes
    2. No
29. Is he or she noise sensitive?

    1. Yes
    2. No
30. Does he or she self stimulate (stimming)?

    1. Yes
    2. No
32. Does he or she have seizures?

    1. Yes
    2. No
33. Is he or she touch sensitive?

    1. Yes
    2. No
34. Does he or she run from home?

    1. Yes
    2. No
36. If he or she does run or wander from home or school, where do they usually go?
38. If he or she is non-verbal, what are the preferred methods of communication?
40. Does he or she have a favorite topic of conversation or favorite toy, song or snack? Please describe
42. Does he or she have a history of violent behavior?

    1. Yes
    2. No
43. If you answered 'Yes', please briefly describe behavior
45. Does he or she have a history of drug or alcohol abuse?

    1. Yes
    2. No
46. If yes, please describe type of abuse
48. What fears, anxieties or triggers does he or she have?
50. Please share any additional pertinent information here
52. Parent, Guardian and Custodian Contact Information
    Please fill out completely
54. Please select one: Parent, Guardian or Custodian
    -- Select One --ParentGuardianCustodian
55. Phone Number*
57. First Name*
58. Last Name*
60. Address1*
62. Address2*
64. City*
65. State*
66. Zip
68. Secondary Contact
    Please fill out completely
70. Please select one: Parent, Guardian or Custodian
    -- Select One --ParentGuardianCustodian
71. Phone Number
73. First Name
74. Last Name
76. Address1
78. Address2
80. City
81. State
82. Zip
84. Release*
    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.
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86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit

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