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2. Name of Person Completing Form
3. Email

5. Please complete the form below with the registrants information. You do NOT have to complete the entire form in order to register. If you are unsure of any information, you can skip and provide the information at a later date if needed. 

7. Registrant Personal Information
9. Legal First Name*
10. Legal Middle Name
11. Legal Last Name*
13. Nickname

    Name the registrant responds to

14. Date of Birth*
16. Home Address*
18. City*
19. State*
20. Zip Code*
22. Parent or Guardian Name*
23. Parent or Guardian Phone Number*
25. Parent or Guardian Name
26. Parent or Guardian Phone Number
28. Race
29. Gender
30. Weight
31. Height
33. Hair Color
34. Eye Color
35. Distinguishing Features

    Birth marks, Scars, Facial Hair, Tattoos, etc.

37. Disability/Special Need
39. Primary *
40. Co-Existing
42. Please check all that apply

    1. ADHD
    2. Aggressive with Police/Fire
    3. Asthma
    4. Autism
    5. Bi-Polar

    1. Down Syndrome
    2. Epilepsy
    3. Hearing Impairment
    4. History of Baker Act
    5. Mentally/Memory Impaired

    1. Mobility Issues
    2. Oppositional Defiant Disorder
    3. PTSD
    4. Seizures
    5. Sensory Issues

    1. Speech Impairments
    2. Traumatic Brain Injury
    3. Visual Impairment
    4. Physical Disability
44. Communication

    1. Verbal
    2. Nonverbal
45. If nonverbal, how does the registrant communicate?
46. Triggers
48. Recommendations for Best Approach for First Responders
49. Medications
51. Diagnosing Specialist/Doctor
53. In Case of Emergency
55. Emergency Contact 1 Name
56. Emergency Contact 1 Phone Number
57. Relationship
59. Emergency Contact 2 Name
60. Emergency Contact 2 Phone Number
61. Relationship
63. Emergency Contact 3 Name
64. Emergency Contact 3 Phone Number
65. Relationship
67. Does the registrant have a cell phone or smart device?

    1. Yes
    2. No
68. Mobile Carrier
69. Cell Phone Number
71. Please Upload Two Photos of the Registrant
73. Portrait

    PNG or JPEG of the registrant's face

74. Full Frame

    PNG or JPEG including the full body frame of the registrant

76. Vehicle Information

    If you are planning on placing a decal on your vehicle, please provide the following information

78. Vehicle Make
79. Vehicle Model
80. Vehicle Color
82. License Plate Number
83. License Plate State
85. RELEASE OF INFORMATION
87. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that you are the lawful and legal parent and/or guardian of the person with special needs and you understand the information provided to the Opelika Police Department is for law enforcement to have all the necessary information to better handle a situation and that some information may be subject to public records laws. 

    1. I agree.
89. Electronic Signature

91. It is the responsibility of the parent and/or guardian to update the information submitted as needed (i.e. physical changes, address changes, change in emergency contacts, etc.)

    Please allow 3-5 days for our Communications Team to add the registrant to the system. 

    
    

Leave This Blank:


93. 1. Receive an email copy of this form.
94. Email address

    This field is not part of the form submission.

95. Submit

* indicates a required field