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Hoboken Police Department

Special Needs Emergency Contact Form

Name of Individual with Special Needs

Gender

Female

Male

Weight

Eye Color

Hair Color

Scars or identifying marks:

Medical Diagnosis

Please list all diagnoses

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Home Phone

Other Phone

Methods of Communication, if non-verbal (sign-language, tablets, picture boards, written word, etc.):

Identification worn (medical alert jewelry, tracking monitor, clothing tags, etc.):

Inclination for wandering behaviors or characteristics that may attract attention:

Favorite attractions and locations where person may be found IF MISSING (parks, stores, restaurants, homes of relatives and/or friends):

If person is found, please describe the best method to be approached. Please include your child's likes and dislikes, including hobbies, food preferences, toys, fears, etc.:

Are there any:

Sensory Issues (loud noises, crowds, surprise human touch, poor balance, uncoordinated movements, high tolerance to pain, "thrill-seeker", etc.):

Dietary Restrictions (food allergies, Gluten sensitivity, special diet, etc):

Medical Issues (allergies, need of inhaler, side effect of medication, etc):

Name of School or Daycare:

Contact Person

Phone

Medical Care Providers:

Name

Phone

Name

Phone

Name

Phone

Parent/Caregiver #1:

Phone

Best Contact Phone

Parent/Caregiver #2:

Phone

Best Contact Phone

Emergency Contacts:

Name

Phone

Name

Phone

Name

Phone

Upload File(s): Attach a blueprint of drawing of home, with bedrooms of individual highlighted

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Please check below if information can be released to:

School Systems

Additional law enforcement agencies, if needed

Hoboken Police Department

Special Needs Emergency Contact Form

Gender

Date of Birth

Medical Diagnosis

Address:

School or Daycare Address

Address

Address

Upload File(s): Attach a blueprint of drawing of home, with bedrooms of individual highlighted

Please check below if information can be released to: