Form

Special Needs Alert Form

Please fill out the document below to help Brown County Public Safety to identfy and notify first responders of any special needs that may be involved so they can address the situation to suit the individuals in need better.

First Name: Middle Initial: Last Name: Address: City, State, Zip: Date of Birth: Preferred Name: Sex: Male Female Height: Weight: Hair Color: BrownBlondeRed Eye Color: BrownBlueHazelGreen Identifying Marks/Scars: Primary Diagnosis/Disability: Other Relevant Medical Condition/Behaviors in Addition to Primary Diagnosis/Disability (Check all that apply): No Sense of Danger Prone to Seizures Blind Deaf Non-Verbal Cognitive Impairment Combative/Aggressive Other- Please Explain Explain: Prescription Medications Needed, Sensory or Dietary Issues, If Any: Method of Preferred Communication (Verbal:words, songs, etc. Non-Verbal: sign language, pictures, etc): Emergency Contact Information- Name Phone Number and Address: Any Additional Information for Responders: Information May Be Released to the Following: Law Enforcement Staff EMS Fire Fighters Dispatchers First Responders Medical Personnel Information to be Released: Any Limited- See Below List Any Information not to be Released: This Authorization is voluntary. Refusal to sign will not affect responder's efforts to assist the record subject: No Exceptions Exceptions (please specify below) List Exceptions: Will This Authorization Expire? Authorization Will Expire (list date below) Authorization Will Not Expire Authorization Expiration Date: As Evidenced by my Signature, I Hereby Authorize Disclosure of Records to the Responder(s) or Agency(s) Specified above within Brown or Surrounding Counties: Date:

Completion of this form authorizes the release of informaton described. The person (record subject) whose records are released may have a right to inspect and , upon paying any applicable fees, obrain a copy of the disclosed records. Information will be released to Public Safety Responders when it will improve their response to the person listed below.