Autism Awareness Sticker Form

AUTISM EMERGENCY INFORMATION FORM

Name of child or adult with Autism *

Nickname if any: *

Date of Birth *

Height *

Hair and Eye Color *

Weight *

Scars or Identifying Marks *

Medical Conditions *

Address *

Address

City

State/Province

Zip/Postal

Country

Home Phone *

Cell Phone *

Method of communication, if non verbal: indicate sign language, picture boards, written word, etc

Identification Worn (Ex: jewerly/medical alert,clothing tags, ID card, tracking monitor, etc)

Current Prescriptions ( include dosage )

Sensory, Medical or Dietary issues and requirements (If Any)

Inclination for wandering behaviors or characteristics that may attract attention

Favorite attractions and locations where person may be found if missing

Likes and Dislikes ( Include approach and De-Escalation Techniques)

1. Name of Medical Care Provider

Phone

2. Name of Medical Care Provider

Phone

3. Name of Medical Care Provider

Phone

Name of Parents/Caregiver

Phone

Address

City

State/Province

Zip/Postal

Country

Any other important information that we should know

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