Community Assistance Information Form

The purpose of this form is to assist the Monrovia Police Department in responding effectively and compassionately to emergencies involving individuals with disabilities, autism, or dementia.

All information will be kept confidential and used only to enhance the safety and well-being of the individual and their family in emergency situations.

Submitter's Information

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Submitter's Information

Full Name

Address

Phone Numberext.

Email Address

Relationship to Individual

Emergency Contact (if different from above)

Emergency Contact (if different from above)

Full Name

Phone Numberext.

Relationship to Individual

Individual's Information

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Individual's Information

Full Name

Date of Birth

Address (if different from submitter)

Primary Language

Description of Individual

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Description of Individual

Height

Weight

Hair Color

Eye Color

Identifying Marks (e.g. tattoos, scars)

Photograph (optional but recommended) Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

Primary Diagnosis/Condition

Primary Diagnosis/Condition

Autism

Dementia/Alzheimer's

Developmental/Physical Disability

Other If other, type text here.

 Behavioral Considerations

Behavioral Considerations

Does the individual have sensory sensitivities (e.g., loud noises, lights)?

Known triggers that may cause distress

Calming techniques or objects that help (e.g., specific words, toys):

Communication

Communication

Verbal/Non-verbal

Uses assistive devices (e.g., communication board, hearing aids):

Preferred method of communication:

Medications

Medications

List of medications

Allergies

Safety Concerns

Safety Concerns

Tendency to wander/run away

Locations they might go if lost

Any fears or phobias (e.g., animals, vehicles)

Special precautions responders should take

Consent and Release

I, the undersigned, understand that the information provided in this form will be used solely to assist law enforcement and emergency services in responding to situations involving the individual listed above. I consent to the Monrovia Police Department retaining this information securely for this purpose.

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I Agree

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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