Form Center

2. About This Form

   This form is meant for community members to submit on behalf of a child, dependent adult, or themselves detailing special considerations law enforcement should take upon contact with that individual. This information will be used to by deputies to formulate a specialized response should the individual need to be contacted during a law enforcement investigation.

4. Child/Dependent Adult Information

   Please include as much detail as possible.

6. First Name of Child/Adult*
7. Last Name of Child/Adult*
9. Address of Child/Adult*
11. Address 2
13. City*
14. State
15. Zip
17. Date of Birth
    Date of Birth
18. Height
19. Weight
20. Eye Color
22. Hair Color
23. Phone Number 1
24. Phone Number 2
26. Medical Conditions

    Please list all relevant medical conditions. This information will be kept confidential and will only be used to inform law enforcement response.

28. Clinician/Therapist
29. School
31. Method of Communication

    If non-verbal: sign language, picture board, written board, etc.

35. Emergency Contact Information
37. Emergency Contact Person
39. Emergency Contact Address
41. Address 2
43. City
44. State
45. Zip
49. Special Considerations

    Please include all information applicable.

51. Behavioral Concerns/Wandering/Sensory Sensitivities/Stemming Movements, Self Harm/Etc.
53. Favorite attractions or locations where person may be found if missing:
55. Recommended approach and de-escalation techniques:
59. Disclaimer

    By checking the box below, I acknowledge that I am providing the above information voluntarily and have the authority to do so. I understand the purpose of this form is to provide first responders with information and resources that will allow them to better serve individuals within our community affected by disabilities and mental illness. By submitting this form, it is understood that this information will be maintained by the Humboldt County Sheriff's Office for use when interacting with the subject described, I also understand that the information can be removed from our database at any time by submitting a written request to do so. 

61. Select After Reading Disclaimer

    1. I understand.
63. Completed By*

    Enter your first and last name.

64. Relationship to Individual*
66. Today's Date
    Today's Date
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit Submit and Print

* indicates a required field