Form Center

Autism & Special Needs Registry

2. Introduction
   Please complete and submit this form if you have a loved one with autism and/or special needs who lives in the City of West Allis or spends a significant amount of time in the City of West Allis. Note: We recommend re-submitting this form with updated information on an annual basis. Information that has been on file for more than a year will periodically be purged.

   Please complete and submit this form if you have a loved one with autism and/or special needs who lives in the City of West Allis or spends a significant amount of time in the City of West Allis. Note: We recommend re-submitting this form with updated information on an annual basis. Information that has been on file for more than a year will periodically be purged.

4. Instructions
   Complete the below fields as it pertains to the person with autism and/or special needs.

   Complete the below fields as it pertains to the person with autism and/or special needs.

6. Last name:*

8. First name:*

10. Middle name:

12. Nickname:

14. Gender:*
    -- Select One --MaleFemale

16. Race:*

18. Skin complexion (e.g., fair, light skinned, dark):*

20. Date of birth:*

22. Hair color:*

24. Eye color:*

26. Height:*

28. Weight:*

30. Body build (e.g., thin, stocky, large):*

32. Scars, marks, tattoos:

34. Description of person's special need(s):*

36. Specific location(s) this person will normally be in the City of West Allis:*

38. Home address:*

40. Home city:*

42. Home state:*

44. Home zip code:*

46. Home phone number:

48. Other phone number:

50. Other phone number:

52. Name of school, camp, or facility person is affiliated with:

54. Phone number of school, camp, or facility person is affiliated with:

56. Remarks about school, camp, or facility:

58. Language spoken:*

60. Describe best method of communication(s) (e.g., verbal, written, sign language):*

62. Describe best methods of approach and de-escalation with the person:*

64. Describe any forms of identification carried by the person (e.g., identification bracelet):

66. Describe any places or locations person may be attracted to:

68. List any names of people in the area that the person might seek out (include phone number(s) and relation of person):

70. Describe any life threatening medical concerns of the person:

72. Provide any other relevant information about the person:

76. Instructions
    Complete for the below fields as it pertains to the person completing this form:

    Complete for the below fields as it pertains to the person completing this form:

78. Relation to person with autism or special needs:*

80. Last name:*

82. First name:*

84. Middle name:

86. Home address:*

88. Home city:*

90. Home state:*

92. Home zip code:*

94. Home phone number:*

96. Other phone number:*

98. Other phone number:

100. Employer:

102. Employer address:

104. Employer city:

106. Employer state:

108. Employer zip code:

112. Instructions
     Complete the below fields as it relates to a secondary emergency contact (if applicable):

     Complete the below fields as it relates to a secondary emergency contact (if applicable):

114. Relation to person with autism or special needs:

116. Last name:

118. First name:

120. Middle name:

122. Home address:

124. Home city:

126. Home state:

128. Home zip code:

130. Home phone number:

132. Other phone number:

134. Other phone number:

136. Employer

138. Employer address:

140. Employer city:

142. Employer state:

144. Employer zip code:

148. Enter any other information you think is relevant:

150. Attach a photo of the person (required):*

152. Attach a photo of the person (optional):

154. Attach a photo of the person (optional)

Leave This Blank:


156. 1. Receive an email copy of this form.
157. Email address

     This field is not part of the form submission.

158. Submit

* indicates a required field