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VACATION PREMISE ALERT REQUEST FORM
We will be
vacationing in your town or resort from _____________________to __________________ Please destroy this form after our
departure date.
Please make your officers aware that a special needs individual is visiting your area and may require
additional assistance.
Name and birth date of individual:
Nombre y fecha de nacimiento del la persona: _________________________________________
attach recent
Photo here
Current physical description of individual:
foto reciente
Una descripcion fisica actual de la persona: Male [ ]
Female [ ]
Height___________ Weight______________
Altura
Peso
Eye
color______________ Hair color______________
color de pelo
color de ojo
Scars or other identifying marks:
Cicatrices u otras marcas que identifican:________________________________________________
_______________________________________________________________________________________
Any Medical conditions:
Cualesquiera condiciones [ ] Blind/Persiana [ ] Deaf/sordo
[ ] Mental
Retardation/Retraso Mental [ ] Mental Illness/Enfermedad mental [ ] Autism
[ ] Physical Disability/Inhabilidad fisica [ ] Diabetes [ ] Seizure/ataque
[ ] Alzheimer’s
[ ] Other/Otro:____________________________________________
Prescription
medications needed:
medicación médicas de la prescripción: ___________________________________________________
Name of parents or care providers:__________________________________________________________
Nombre de padres
o cuidado del nino:
Address/Dirección ________________________________________________________________________
Phone numbers/Número de teléfono:
Home/ Casa _______________________________ Cell phone/ Teléfono cellular _____________________
Pager/Beeper ___________________________ TDD/TTY_______________________________________
Name of alternative emergency contact person:
Alternativa de la persona del
contacto Nombre: _________________________________________________
Phone numbers/Número de teléfono:
Home/ Casa__________________________________
Work/ Trabajo________________________ Cell phone/ Teléfono
de la célula _________________________
Pager/ Beeper__________________________ TTY/TDD_________________________________________
Is he/she likely to wander off?
¿El o ella le gusta vagar en diferentes sitios? __________________________________________________
Favorite
attractions or locations where they may be found:
Localizaciones preferidas en donde pueden ser encontrados:_______________________________________
_______________________________________________________________________________________
Atypical behaviors
or characteristics that may attract attention:
Comportamientos o características anormales que pueden atraer la
atención:___________________________
_______________________________________________________________________________________
Favorite toys, objects or discussion topics likes, dislikes:
Juguetes preferidos, objetos o asuntos de
discusión que le gustan o no le gustan:_______________________
_______________________________________________________________________________________
Approach, calming or de-escalation techniques most likely to work:
Técnicas del acercamiento para
calmarlo: ______________________________________________________
_______________________________________________________________________________________
Method of communication, if nonverbal, sign language, picture board, written words:
Método de comunicación,
si no es verbal, lenguaje por signo, palabras escritas, letreros:_________________
_______________________________________________________________________________________
ID information. Do they carry or wear jewelry, tags, ID card:
Información de identificación.
Usan joy as, etiquetas, tarjeta de identificación: ________________________
_______________________________________________________________________________________
Your answers to these questions may assist police, fire, or medical personnel when
they are responding to an emergency or other call from your home, in identifying and/or assisting you, or a person in your
household who has a disability. There is no guarantee that this information will be accessed in the event of an emergency.
This form is owned by SNM Inc and is protected by copyright laws. PERMISSION: You are permitted and encouraged to reproduce
and distribute this material in any format if you do NOT alter the wording in any way, you do not charge a fee beyond the
cost of reproduction, and you give credit to the author. (c) 2003-7
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