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2. 
6. First Name*
7. Middle Name
8. Last Name*
10. Race*
11. Gender*
12. Date of Birth*
14. Height*
15. Weight*
16. Eye Color
17. Hair Color*
19. Identifying Features
23. Address*
24. City*
    -- Select One --Sterling Heights
25. Zip Code*
26. Apt./Unit #
28. Contact Number*
29. Residence Type
    -- Select One --House/DuplexApartment/CondoMobile HomeGroup HomeOther
33. Condition*
    -- Select One --ADHDMemory LossParanoiaHearing Disorders/DeafnessLearning DisabilitySpeech (e.g. Stuttering)StrokeVoice ProblemsBrain InjuryCerebral PalsyWilliams SyndromeFragile X SyndromePrader-WilliDown SyndromePhenylketonura (PKU)AphasiaArthritisAsthmaCancerChronic Fatigue SyndromeConcussionDiabetesGastrointestinal DisorderHeart DiseaseOrthopedic LimitationsSeizure DisorderManiaPost Traumatic Stress DisorderAnxiety DisorderBipolar DisorderClinical DepressionEating DisorderObsessive Compulsive DisorderPsychosisSchizophreniaFetal Alcohol SyndromeDementiaAlzheimer's DiseaseAutism
34. Primary Diagnosis
    -- Select One --Behavior DisorderCognitive DisabilitiesCognitive/Mental Psychiatric DisorderCommunication DisordersCommunication/Neurologic DisorderDevelopmental/Neurological DisorderGenetic Disorder/Cognitive DisabilityGenetic Disorder/Intellectual DisabilityLanguage DisabilityMedical DisabilityMental/Psychiatric Disability
36. Co-existing Condition (if needed)
    -- Select One --ADHDMemory LossParanoiaHearing Disorders/DeafnessLearning DisabilitySpeech (e.g. Stuttering)StrokeVoice ProblemsBrain InjuryCerebral PalsyWilliams SyndromeFragile X SyndromePrader-WilliDown SyndromePhenylketonura (PKU)AphasiaArthritisAsthmaCancerChronic Fatigue SyndromeConcussionDiabetesGastrointestinal DisorderHeart DiseaseOrthopedic LimitationsSeizure DisorderManiaPost Traumatic Stress DisorderAnxiety DisorderBipolar DisorderClinical DepressionEating DisordersObsessive Compulsive DisordersPsychosisSchizophreniaFetal Alcohol SyndromeDementiaAlzheimer's DiseaseAutism
37. Co-existing Diagnosis
    -- Select One --Behavior DisorderCognitive DisabilitiesCognitive/Mental/Psychiatric DisabilityCommunication DisorderCommunication/Neurologic DisorderDevelopmental/Neurological DisorderGenetic Disorder/Cognitive DisabilityGenetic Disorder/Intellectual DisabilityIntellectual DisabilityLanguage DisabilityMedical DisabilityMental/Psychiatric Disability
39. Critical Information (Communication needs, etc.)*
41. De-escalation Techniques*
43. Behavior Triggers*
45. Medical Information*
49. Relationship to Person of this Application*
    -- Select One --ParentGuardianSelf (if over 18 years old)Family (Immediate Family)
50. Upload Photo
52. Parent/Guardian Name*
53. Primary Phone*
54. Secondary Phone
55. E-mail*
57. Second Parent/Guardian Name
58. Primary Phone
59. Secondary Phone
60. E-mail
62. Release of Information*

    1. I, hereby give my permission for the Sterling Heights Police Department and Macomb County Sheriffs Dispatch Center 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 a crisis or emergency situation.
64. Release of Photograph*

    1. I, hereby give my permission for the Sterling Heights Police Department and Macomb County Sheriffs Dispatch Center to retain and distribute the photograph contained with this registration form to other first responder personnel for the sole purpose of identification and protection of the person identified above in a crisis or emergency situation.
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66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

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