Children with Autism and Intellectual Impairments

The Bristol Police Department would like your assistance with the creation of a program which will identify the homes of children with Autism and Intellectual Disabilities.

This program is being implemented to improve the safety of your children if or when they interact with the police. The first course of action is to identify where these children reside.

The addresses will be shared with the police department in order to provide our officers with important pre-arrival information should a call for service be facilitated to your residence. This program would help the officers to minimize the possibility of creating distress for the children and create a positive interaction with the police.

“The true measure of any society can be found in how it treats its most vulnerable members”

The true measure of any society can be found in how it treats its most vulnerable members.

If you are interested in participating in this program, please complete the form below:

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Autism and Intellectual Disabilities

The Bristol Police Department would like your assistance with the creation of a program which will identify the homes of children with Autism and Intellectual Disabilities.

Child Information

Biological Information

Emergency Contact

Additional Information

Release

Program Withdrawal

Child's First Name:*

Child's Last Name:*

Address:*

City:*

Please select

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State:*

Zip Code:*

Parent(s) or Guardian(s) Name:*

 

Biological Information

First Name:*

Last Name:*

Date of Birth:*

Sex:*

Race / Ethnicity:*

Height:*

Weight:*

Hair Color:*

Eye Color:*

Glasses:

Yes

No

Diagnosis:

Please provide a recent color photo.*

 Upload

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Home Address:*

School Name:*

Physician:

 

Emergency Contact Information

Name:*

Address:*

City:*

State:*

Zip:*

Relationship:*

Email:

Primary Hospital Choice:

 

Additional Information

Allergies:

Speech:

Verbal

Non-Verbal

If non-verbal, please indicate the preferred method of communication, i.e. sign language, photos, word approximation.

Non-Verbal Communication Method:

Ambulatory

Yes (Ambulatory)

No (Non-Ambulatory)

Is this person able to walk?

Medical Alert or ID:

Describe medical alert ID or other identifying information carried or worn.

Please list any favorite places that your child may frequent, or go to:

Will your child respond to his/her name?

Yes

No

Does child/family use a password?

Yes

No

If you are using a password, please provide it here:

Important information that will help assist personnel to communicate, understand, care for and maintain the safety of this person.

 

Release

I voluntarily give my permission to the Town of Bristol to retain and distribute this information to first responders for the sole purpose of identification and assistance to the person at risk. This information will be kept in the strictest form of confidentiality within the Bristol Police Department. I hereby waive any HIPAA claims that may exist upon the release of information contained on this document.

Signature

Full Name:

Date:

Time

 

Emergency Medical Information Program Withdrawal

I am voluntarily withdrawing from the Bristol Police Department’s Emergency Medical Information Program, and request all information obtained by the Bristol Police Department that pertains to me, for the sole purpose of this program, be deleted. I release and discharge the Town of Bristol, its successors, subsidiaries, employees, officers, directors and agents for all claims and liabilities, demands and causes of action known or unknown. Fixed or contingent, which I have claim to have against the Town of Bristol as a result of this withdrawal and do hereby agree not to file a lawsuit to assert such claims.

Signature

Full Name:

Address:

Date:

Time

Email

 

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