2. 
6. Wheeling Police Department Return Home Safe Application
8. Person with Disability - Information
10. Name
11. Nickname
13. Date of Birth
14. Gender
15. Race
17. Eye Color
18. Height
19. Weight
20. Hair Color
22. Physical Description (Scar, Marks, Tattoos, Glasses)
24. Physical Description (Scar, Marks, Tattoos, Glasses) Line 2
26. Diagnosis - Line 1
28. Diagnosis - Line 2
30. Diagnosis - Line 3
32. Verbal/Non Verbal
33. Language(s) Spoken
35. Method of Communication
37. Address
39. Home Phone
40. Cell Phone
42. Name of Parent, Guardian, Caregiver
44. Name
45. Relationship
47. Address
49. Home Phone Number
50. Cell Phone Number
52. Email Address
54. Name of Other Family Members or Cargivers
56. 1. Name
57. Relationship
59. Home Phone Number
60. Cell Phone Number
62. 2. Name
63. Relationship
65. Home Phone Number
66. Cell Phone Number
68. 3. Name
69. Relationship
71. Home Phone Number
72. Cell Phone Number
74. 4. Name
75. Relationship
77. Phone Number
78. Fax Number
80. **** Please list the additional Family Members in order of preference of contact ***
82. Medical Information
84. Primary Care Physican
86. Medications - Line 1
88. Medications - Line 2
90. Allergies - Yes or No
91. List Allergies
93. Requires use of Oxygen - Yes or No
94. If yes, how many liters
96. Life Threatening or Other Serious Medical Conditions
100. Miscellaneous
102. Does the person respond when called by name?
104. Has the person ever run away or been reported missing?
105. If yes, where were they located?
107. Is the person attracted to water?
108. If yes, do they know how to swim?
110. Does the person have any attractions to a specific location?
112. Is the person familiar with the area and vehicular traffic?
114. How does the person respond to being touched?
116. Are they scared of Emergency Personnel?
118. Does the person have any loud trigger such as loud noises, flashing lights, etc.?
120. Any other relevant information (such as favorite toys, specific interests, etc.)
122. Upload Photo Here - Make sure photo clearly shows the applicants face*
126. By filling out the appropriate registration, residents and their parents/guardians are consenting to have this information added to the Wheeling Police Department's searchable database. The information provided will be available to law enforcement, paramedics and firefighters responding to a home or any location within Wheeling involving a registered participant and will assist with efforts in providing safe, effective and appropriate responses. This information is voluntary and can be rescinded at any time. It will be confidential and used only in the event that assistance is needed. It is the responsibility of the primary caregiver to update any changes to the information.
128. Please contact Sgt. Giltner or Ofc. Kim if you have questions pertaining to the program at, 847-459-2632.
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134. 1. Receive an email copy of this form.
135. Email address

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136. Submit

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