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Wheeling Police Department Return Home Safe Application
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Wheeling Police Department Return Home Safe Application
Person with Disability - Information
Name
Nickname
Date of Birth
Gender
Race
Eye Color
Height
Weight
Hair Color
Physical Description (Scar, Marks, Tattoos, Glasses)
Physical Description (Scar, Marks, Tattoos, Glasses) Line 2
Diagnosis - Line 1
Diagnosis - Line 2
Diagnosis - Line 3
Verbal/Non Verbal
Language(s) Spoken
Method of Communication
Address
Home Phone
Cell Phone
Name of Parent, Guardian, Caregiver
Name
Relationship
Address
Home Phone Number
Cell Phone Number
Email Address
Name of Other Family Members or Cargivers
1. Name
Relationship
Home Phone Number
Cell Phone Number
2. Name
Relationship
Home Phone Number
Cell Phone Number
3. Name
Relationship
Home Phone Number
Cell Phone Number
4. Name
Relationship
Phone Number
Fax Number
**** Please list the additional Family Members in order of preference of contact ***
Medical Information
Primary Care Physican
Medications - Line 1
Medications - Line 2
Allergies - Yes or No
List Allergies
Requires use of Oxygen - Yes or No
If yes, how many liters
Life Threatening or Other Serious Medical Conditions
Miscellaneous
Does the person respond when called by name?
Has the person ever run away or been reported missing?
If yes, where were they located?
Is the person attracted to water?
If yes, do they know how to swim?
Does the person have any attractions to a specific location?
Is the person familiar with the area and vehicular traffic?
How does the person respond to being touched?
Are they scared of Emergency Personnel?
Does the person have any loud trigger such as loud noises, flashing lights, etc.?
Any other relevant information (such as favorite toys, specific interests, etc.)
Upload Photo Here - Make sure photo clearly shows the applicants face
*
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 This information is voluntary and can be rescinded at any time.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.
Please contact Sgt. Giltner or Ofc. Kim if you have questions pertaining to the program at, 847-459-2632.
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