06/18/2024
Autism Registry
Please complete and return to Mogadore Fire Department 135 S. Cleveland Ave
Person with Autism:
Formal Name: ______________________________
Nickname: _________________________________
Address: __________________________________
DOB: _________ S*x: _________Race: __________
Height: ____Weight: _____Hair: ______Eyes: ______
Other Physical Descriptors: ____________________
____________________________________________ Emergency Contacts
Name: ___________________________
Relationship: ______________________
Phone: ___________________________
Name: ____________________________
Relationship: ______________________
Phone: ________________________
Medical Needs/Allergies
Safe Places__________ can be taken to:
Behaviors When Unhappy/Upset
Places __________might be found at:
Likes:
Dislikes:
See back for further information
Autism Registry cont.
Places __________really like to go:
Places __________ may be hiding:
Soothing Calming Techniques:
Any other helpful information:
Photograph, if available
Release of Information
I hereby give my permission to Mogadore Fire Department to retain and distribute the information contained in this registration form to other First Responders, (including, but not limited to: Police, Fire, EMS, Rescue and Dispatchers) for the sole purpose of identification and protection of the person identified above, in the event of an emergency or crisis.
Signature:__________________________
Today’s Date:________________________