Person With Disability
Emergency Information Instructions
Attached to this cover
sheet is the Person With Disability Emergency Information form. Below please
find instructions for completing this form, as well as answers to commonly asked questions.
INSTRUCTIONS:
1.
The form must be completed in its entirety by a parent, guardian or person with power of attorney.
2.
Two recent photos should be attached to the form. (The photo can be of any size, but must show a clear view of the persons face.)
3.
This form must be turned in by a parent, guardian or person with power of attorney to the Champaign Police
Department or Urbana Police Department’s front desk.
4.
Any questions please contact either of the following individuals:
Jonathan Westfield
Champaign Police Department
School Resource Officer
(217) 403-6942
westfijd@ci.champaign.il.us
Inv. Dave Smysor
Urbana Police Department School
Criminal Investigations Division
(217) 384-2330
smysordg@city.urbana.il.us
FREQUENTLY ASKED QUESTIONS:
1. How did this system come about? The
Autism Society of Illinois-The C-U Autism Network collaborated with the Cities of Urbana and Champaign. The purpose was to create a method to provide critical information to emergency responders in the event
of a crisis.
2. Why is this important? A first responder may come into contact with individuals with disabilities on an emergency
call or even calls for missing persons. The first responder will now have access
to critical information about the individual that will help deescalate the situation.
Also, a photo will be quickly accessible for those who are missing.
3. Is this information confidential?
Yes, all files will be kept in a secure area at both police departments and
will not be accessible to the public. The information will only be accessed in
an emergency situation and will not be used for any other purpose.
4. Do I have to update this information? Yes, preferably every year.
However, if the agencies are not contacted by the end of the second year, the information will be purged by both agencies.
5. What if I decide that I no longer want to have this information on file? Simply contact Jonathan or Dave and request
that this information be deleted. Jonathan and Dave will need to meet with you
in person to verify that the person who signed the form is the same person who is requesting that the information be deleted.
PERSON WITH DISABILITY-EMERGENCY INFORMATION
Please print legibly and attach two current photos
Name: _____________________________________________________________________________
Last
First
Middle
Nickname: ____________________________ Date of Birth: ________/______/________
Address: ___________________________________________________________________________
City: ______________________
State: ____ Zip Code: ______ Tel:
(____) ______________
School/Employer: ___________________________________________________________________
Address: ___________________________________________________________________________
City: ______________________
State: ____ Zip Code: ______ Tel:
(____) ______________
Primary Disability: ______________________________
DESCRIPTION
Race: _________
Sex: m f Height: ______ ft _____ in Weight:
______ lbs
Hair: __________
Eyes: ___________
Special Identifiers (scars/ marks/ tattoos/piercing): _______________________________________
EMERGENCY CONTACT INFORMATION
Parent/Guardian(s):__________________________________________________________________
Address: _________________________________
City: _________ State: ____ Zip Code: _______
Home Tel: (____) ________________
Cell/Work Tel: (____) ________________
ADDITIONAL EMERGENCY CONTACT INFORMATION
Emergency Contact: _________________________________________________________________
Address: _________________________________
City: _________ State: ____ Zip Code: _______
Home Tel: (____) ________________
Cell/Work Tel: (____) ________________
PERSON WITH DISABILITY-EMERGENCY INFORMATION
Method of Communication: ___________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Atypical Behavior or Characteristics that might attract attention:____________________________
___________________________________________________________________________________
___________________________________________________________________________________
Sensory, Medical, Dietary Issues: ______________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Approach and De-Escalation Techniques:________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Favorite Objects or Discussion Topics: __________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
I, __________________________, parent/guardian of above-named individual,
give the Champaign and the Urbana Police Departments permission to keep this photo and information regarding my son/daughter
for emergency purposes only. I understand that my child's name will be entered into the ARMS system with an alert added to
their name. I understand that my child’s name will be entered into a premise file in Tiburon – CAD Database. I understand that the information contained herein is for the CPD and UPD's internal
information ONLY and cannot be accessed by others. I understand that it is my responsibility to annually update the above
information and provide it to either the Champaign or Urbana Police Departments.
__________________________________________
_______/_______/________
(Parent/Guardian Signature)
(Date)
