Autism Safety Roster

What is the Autism Safety Roster?
The Autism Safety Roster is a project in partnership between the community members of Lakewood and the Lakewood Police Department. This online roster promotes communication and enables the police department to have quick and relevant access to important information about a person with Autism. This information may be crucial in instances where affected persons wander or are experiencing a crisis situation.

The information submitted about the person may include: name, birthday, physical description, emergency contact information, known triggers/behaviors and more. Having early access to this information may prove crucial to successfully defusing a crisis situation or locating a person that has wandered away from safe surroundings.

Goal of the Program

The goal is to help ensure the safety of an individual with Autism or any other, related, Autism Spectrum Disorder.

How to Register

To register, an adult family member — or guardian of an individual with Autism (or any related, Autism Spectrum Disorder) — will complete and submit the online form (below).

What happens once the person is registered?

Once the person is registered, their information will be placed into a searchable database in the Lakewood Police Department’s record management system. This information will then be available to the officers responding to a call for help or assistance with an autistic person. When possible, a specially trained, “Crisis Intervention Team” (CIT) officer will be sent to the scene.

How long does the registration last?

A fresh, new, online form should be submitted at least once each year, or anytime there is a significant change in any of the information provided by the original form.

If it is found that the online form has not been updated in the last two years, the entry will be removed from the database.

Step 1 of 12 - Person Completing This Form

Person Completing This Form
Name*
First Last
Email*
Phone*
Relationship to person with autism*

Person With Autism Information
Full Name*
Date of Birth*
Select EEOC Category*
Gender
Height*
Weight*
Hair Color*
Eye Color*
Scars/Birthmarks/Tattoos

Person With Autism Residential Information
Home Address*
City*
Zip Code*

Parent or Guardian Information
Name of Parent/Guardian*
Primary Phone*
Secondary Phone
Place of Work
Work Address
Name of Other Parent/Guardian
Primary Phone
Secondary Phone
Place of Work
Work Address

Autism Symptomatology
Primary Diagnosis*
Co-existing Diagnosis
Communication*
Describe Communication if Non-Verbal

Wandering
Prior Wandering Incident*
If "Yes," Is There A Place He/She Has Been Found Before?
Closest Water to Residence
Favorite Hiding Place at Home (if applicable)
Favorite Hiding Place in Neighborhood/Community (if applicable)
Respond to Name Being Called?*

Characteristics
Select Sensory Issues*
Select Touch*
Select Sounds*
Select Bright Lights*
Self-stimulatory (Stimming) behavior*
Process Delays?*
Fears
Dislikes/Triggers
Favorite Objects/ Topics
Pre-meltdown Signs
Meltdown Behavior
Calming strategies that work
Physical aggression or prior contact with the police
Weapons in the home?*
Are weapons properly secured?*
Alcohol/Drug Issues?*
Does the Family Have a Crisis Action Plan?*

Emergency Contact Information
Name of the Primary Emergency Contact
Relationship
Address
City
Primary Phone Number
Secondary Phone Number

Other Contact
Case Worker Name
Case Worker Phone Number
Case Worker Agency
Case Worker Agency Phone
School Contact
School Name
School Grade
School Address
School Contact
School Contact Phone

Vehicle Information
Vehicle make, model and year
Vehicle color
Vehicle license plate number

Additional Information
Choose File
Attach a recent photograph... Upload a current photograph that only has the person you are submitting for in the picture. (Required)
Add any additional information

Release & Submit
RELEASE OF INFORMATION I, hereby give my permission for any first responder agency (including but not limited to police, fire/rescue/EMS/911 dispatch center, search and rescue personnel) to retain and distribute the information contained in this registration form to other first responder personnel for the sole purpose of identification and protection of the person identified above in an emergency or crisis situation. By typing your name in the box, you are agreeing to the release terms posted above.
Enter Your Full Name*
Enter Today's Date*

Autism Safety Roster

Step 1 of 12 - Person Completing This Form

Person Completing This Form

Person With Autism Information

Person With Autism Residential Information

Parent or Guardian Information

Autism Symptomatology

Wandering

Characteristics

Emergency Contact Information

Other Contact

School Contact

Vehicle Information

Additional Information

Release & Submit

Recent News

Upcoming Events

Most Popular Pages