Form Center

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.
4. Instructions
   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:
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):
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