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2. The Madison Police Department, is offering a voluntary registry service for people with disabilities who may require special assistance in emergency or crisis situations. This confidential registry may provide essential information that will assist police, fire, EMS and other emergency workers to safely address the needs of residents of all abilities.

   This information is protected and will be stored in our Dispatch CAD system and will only be accessible to dispatchers and 1st Responders when there is a call for service at the corresponding address.  

4. Name of Individual with Autism*
5. Nickname, if any
9. Date of Birth*
10. Gender*
    -- Select One --FemaleMaleNon-binaryTransgenderIntersexI prefer not to say
12. Address*
14. City
15. State
16. Zip Code
18. Height
19. Weight
20. Eye Color*
21. Hair Color*
23. Scars or Identifying Marks*
25. Medical Condition(s)*
27. Method of Communication*

    Vocal, Sign Language, Pictures, Written, Etc. 

29. Other Relevant Conditions in Addition to Autism*

    Check all that apply

    1. No Sense of Danger
    2. Non-Verbal

    1. Attracted to Water
    2. Intellectual Disability

    1. Self Injurious
    2. Prone to Seizures

    1. Aggressive Behavior Under Stress
    2. Other
31. Triggers or Aversions Including Sensory, Medical or Dietary Issues and Requirements, if Any*
33. Inclination for Wandering Behaviors and/or Atypical Characteristics/Behaviors that may Attract Attention of First Responders*
35. Favorite Attractions and Locations Where Person may be Found if Missing*
37. Likes and Dislikes Such as Toys or Conversation Topics*

    Please include known De-Escalation Techniques 

39. Identification Worn*

    Medical Alert, Clothing Tags, ID Cards, Tracking Monitor, Etc. 

41. Other Important Information
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field