Pleasantville VIP FIND ME Registration Form
Attach Photo Here (Head Shot)
Attach Photo Here (Full Body Picture)
Child’s Full Name
Nickname
Primary Diagnosis
Address
Birthdate
Sex
Hair Color
Eye Color
Weight
Height
Distinguishable Marks (Scars, Moles, etc.)
ID Wear, Medical Alert Jewelry, etc.
Mother’s Name (or Guardian)
Home Phone
Work Phone
Cell Phone
Father’s Name (or Guardian)
Home Phone
Work Phone
Cell Phone
Race
Alternate Emergency Contact #1 Name
Home Phone
Work Phone
Cell Phone
Alternate Emergency Contact #2 Name
Home Phone
Work Phone
Cell Phone
School
School Phone
Doctor’s Name
Phone
Allergies
Blood Type
Other Medical Conditions
Medications
Noticeable Behaviors
Verbal
Non-‐-‐Verbal
Language Spoken/ Understood
Partially Verbal
If Partial/ Non-‐-‐Verbal, Methods of Communication (ex: Sign Language, Picture
Board, Written Words, etc.)
Hearing Impaired (Partial or Fully)
Vision Impaired (Partial or Fully)
Glasses? Yes No
Fears (Animals, Sounds, Flashing Lights, etc.)
Favorite Things/ Attractions/ Places
Actions/ Words to Avoid
Helpful Hints to Aid in Approaching
I authorize release of my child’s personal information to the police to be kept on file in the event of an emergency.
Signature of Parent/ Guardian
Date