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2. To be enrolled in the Autism Outreach Program, you must reside in the City of North Miami
4. Autism Spectrum Disorder Participant's Information
6. Last Name, First Name *
7. Preferred Name or Nickname *
9. Date of Birth (MM/DD/YYYY)*
11. Home Address *
12. City*
13. State*
14. Zip Code*
16. Does the Individual live alone? *
    -- Select One --Yes No
17. School

    If applicable 

19. Phone Number*
20. Social Media Usernames
22. Email Address
24. Gender *
25. Race*
26. Height *
27. Weight *
29. Eye Color *
30. Hair Color *
31. Scars, Marks, Tattoos, Piercings
33. Photo
35. Work Address
37. City
38. State
39. Zip Code
41. Work Phone Number
45. Vehicle Information
47. Make
48. Model
50. Tag
51. Color
52. Stickers, Decals, Damage, Etc.
56. Other Relevant Medical Conditions*

    1. No Sense of Danger
    2. Sight and/or Sound Sensitive
    3. Blind
    4. Deaf
    5. Non-Verbal
    6. Intellectual Disability
    7. Cognitive Impairment
    8. Prone to Seizures
    9. N/A
58. If Other, Please Explain
60. Prescription Medication Needed
62. Sensory or Dietary Issues
66. Emergency Contact - Parent, Guardian, Head of Household, Care Provider
68. Name*
69. Relationship to Individual
71. Address*
73. City*
74. State*
75. Zip Code*
77. Primary Phone Number*
78. Secondary Phone Number
80. Email Address
82. Alternative Emergency Contact - Parent, Guardian, Head of Household, Care Provider
84. Name
85. Relationship to Individual
87. Address
89. City
90. State
91. Zip Code
93. Primary Phone Number
94. Secondary Phone Number
96. Email Address
100. Favorite Locations or Attractions Where The Individual May Be Found
102. Individual Likes/Dislikes

     (Toys, Music, Objects, Topics, Etc.) 

104. Method of Preferred Communication

     If non-verbal: Sign language, picture boards, written words, etc

106. Method of Preferred Communication

     If verbal: Preferred words, sounds, songs, phrases 

108. Identification Information

     Does the individual carry an identification card, wear jewelry tags, medical alert bracelet, etc? If so, list above. 

110. Tracking Information

     Does the individual have a Project Lifesaver or Lojack SafetyNet transmitter number? 

112. Atypical behaviors or characteristics of the individual that may attract the attention of first responders
114. Additional information for first responders
118. Autism Decal *
     -- Select One --Yes No

     Would you like to receive a decal to display on your residence window or door, to alert North Miami officers that someone in the home has Autism? 

122. 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.
124. Electronic Signature
Leave This Blank:


126. 1. Receive an email copy of this form.
127. Email address

     This field is not part of the form submission.

128. Submit

* indicates a required field