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Farmington Police Department C.A.R.E. (Children And Residents Encounter) SPECIAL NEEDS QUESTIONNAIRE Name of the person with special needs: Address where this person spends the majority of their time: Street Address: City, State & Zip: Does this person go by a nick name? If so, what? Date of Birth: Age: Diagnosis: List all pertinent names and phone numbers officers may need when dealing with this person: Name: Phone Number: Name: Phone Number: Name: Phone Number: Name: Phone Number: Physical description of the person: Scars, Marks & Tattoos: ---PAGE BREAK--- Height: Weight: Hair Color: Eye Color: Race: Gender: Glasses or Contacts: Glasses Contacts Is there a special interest (outside of their residence) that this person is drawn to? (For example: trains, water, woods, parks, malls, traffic, etc.). Has this person ever ran away or been reported missing? If so, where was he/she found? Is this person verbal or non-verbal? Explain in detail. Does this person fear Police or Fire/EMS personnel or emergency vehicles? Explain in detail. Names of caregivers, parents, grandparents, or other family members involved in this person’s life: Name: Name: Name: Name: Name: Name: Name: Name: Name: Name: ---PAGE BREAK--- If this person becomes confrontational, how could Officers or Rescue Personnel attempt to calm him/her? Are you willing to allow Farmington Police Department to place your address and the information of this person’s needs into the local emergency response system to ensure that officers are better prepared to handle the situation? YES NO Does this person have any triggers (i.e: lights, sirens, loud noises)? Please explain in detail any other important information that we may need to know that might assist us in not triggering a violent response from this person: Address you would like your C.A.R.E. card mailed to: Street address: City, State & Zip: ---PAGE BREAK--- Farmington Police Department C.A.R.E. Release Waiver I, _ give my permission to the Farmington Police Department to release any and all pertinent information related to the care or well-being of _ to (Please initial in the appropriate box(s) below): The San Juan County Communications Center (I realize this information may be released to other agencies via the communications center such as the Farmington Fire Department and Emergency Medical Services). Any and all pertinent information (including photographs) may also be released to media outlets for dissemination and, posted on Farmington Police Department’s media sites in effort to help identify and locate the above mentioned individual. _ _ Signature Date If form is being submitted electronically, my typed name above shall serve as my signature. Please verify by entering one of the following: 1. or 2. _ Your Date of Birth Your Driver’s License # Issuing State SIGN