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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

Vip Find Me registration form  

The VIP FIND ME Program collects pertinent information about our VIP special needs students to be used by our first responders in the case o...

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