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2. Primary Emergency Contact Information
4. Date
   Date
6. Name
7. Email Address
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
16. Fax Number
18. Method of communication?

    (If non-verbal; sign language, picture boards, written words, etc.)

19. Answer
21. Techniques that will attract the individual?

    (Particular voice(mom, dad, etc.), favorite song, etc.)

22. Answer
24. How would the individual react to sirens, helicopter's, search k9s, people in uniform?
25. Answer
27. Best methods of approach?

    (Include approach and de-escalation techniques normally used)

28. Answer
30. Identification worn?

    (Jewelry, Medic Alert, Clothing Tags, ID Card, Tracking Monitor, etc.)

31. Answer
33. Fascinations and/or stimulants?

    (trains, heavy equipment, airplanes, fire trucks, water, active highway)

34. Answer
36. Favorite place to go?
37. Answer
39. If the individual has wandered away before, where was he/she located?
40. Answer
42. Medical, sensory or dietary issues or requirements?
43. Answer
45. Additional relevant information.
47. Answer
49. Secondary Contact Information
51. Name
52. Email Address
54. Address
56. City
57. State
58. Zip Code
60. Phone Number
61. Fax Number
63. Additional Emergency Contact Information
65. Name
66. Email Address
68. Address
70. City
71. State
72. Zip Code
74. Phone Number
75. Fax Number
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77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

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