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2. Name and Information for Person with Disability
4. Name*
6. Nickname (if any)
7. Date of Birth
   Date of Birth
9. Home Address*
11. City*
12. State*
13. Zip Code*
15. Vehicle Plate:
16. Vehicle Description:
18. Guardianship*

    1. I have a guardian (Provide Additional Information Below)

    1. I am my own guardian
20. Guardian Name
21. Guardian Phone Number
23. Guardian Relationship

    1. Parent

    1. Relative/other

    1. Court Appointed
25. Emergency Contact Name*
27. Emergency Contact Phone Number*
28. Emergency Contact Cell Number
30. Physical Description of Person with Disability
32. Height*
33. Weight*
35. Skin Color*
36. Hair Color*
38. Eye Color*
39. Other (tattoos, scars, etc)*
41. Medical Information for Person with Disability
43. Diagnosed Conditions*

    1. Diabetes
    2. Heart Condition
    3. Hypertension
    4. Epilepsy

    1. Latex Allergy
    2. Other Allergy
    3. Other Medical Condition
45. If you selected Other Diagnosed Condition, please describe:
47. Medications (please list all)
49. House Information
51. Information About Your Home For First Responders*
    Ex: where is your bedroom, do you use oxygen, have pets, etc
53. Emergency Key Location
    Do you have a secondary, outside key for emergency purposes?
55. Physical Disability*

    1. Paralysis (Describe further)
    2. Unable to Walk - Equipment Used
    3. Blind/Visually Impaired
    4. Amputee (Describe further)
    5. Other (Describe further)
56. Provide additional information for Physical Disability selection
58. Equipment Use (include service animal)
60. Invisible Disability*

    1. Autism Spectrum
    2. Brain Injury/Cognitive Impairment
    3. Deaf/Hearing Impaired
    4. Mental Health Issues
    5. Non-Verbal
    6. Other (Describe Further)
61. Provide additional information for Invisible Disability selection
63. Verbal Communication

    1. English
    2. Spanish
    3. German
    4. French
    5. Other (Describe Further)
64. Non-Verbal Communication

    1. Sign Language
    2. Picture Board
    3. Written Words
    4. No formal method of communication
    5. Other (Describe Further)
66. If you selected Other for type of communication, please describe:
68. Unique or Special Behaviors
70. May Seem Disrespectful or Threatening
    Explain, ex: yelling, giggles, stands to close)
71. High Anxiety Issues
    Explain, ex: Communication problems, combative, etc
73. Sensory Overload (select what may result from sensory overload)

    1. Seizure
    2. Panic
    3. Flight
    4. Withdrawal
    5. Other (Describe Further)
74. Provide additional information for Sensory Overload selection
76. What might Trigger Sensory Overload

    1. Dog Bark
    2. Siren
    3. Touch
    4. Other (Describe Further)
77. Provide additional information for Trigger Sensory Overload selection
79. What calming mechanisms may work for any of the above behaviors

    1. Lowered Voice
    2. Fewer People Present
    3. No Eye Contact
    4. Other (Describe Further)
80. Provide additional information for Calming Mechanisms selection
82. Favorite Location
    For persons that are a flight risk, is there a favorite location they might be found or do they have a fixation on a particular person, place, or topic
84. All information given on this form is confidential and secure. It will not be shared with any other organizations. Your information is only accessible to Jackson County Dispatch and Emergency Responders.
86. In the event you need to make changes to this information please call Jackson Dispatch Offices at 517-768-7957.
88. Genasys Protect ALERT

    Genasys Protect ALERT is a program to notify Jackson county residents in the event of emergency situations or critical community alerts. Examples include: evacuation Notices, bio-terrorism alerts, boil water notices, and missing child reports. You can enroll for alerts here:  https://jacksoncountymi.genasys.com/portal/en/register 

90. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
92. Electronic Signature*
93. Date*
    Date
Leave This Blank:


95. 1. Receive an email copy of this form.
96. Email address

    This field is not part of the form submission.

97. Submit

* indicates a required field