EFFORT: Special Needs Emergency Information Form

Please fill out as much information as possible. This form is applicable to special needs citizens of Montgomery County, Town of Blacksburg, Town of Christiansburg, and Virginia Tech.

Special Needs Person Information
Project Lifesaver ID# (Optional)
Name*
First Last
Nickname or Preferred Name*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Month
Day
Year
Primary Phone*
Secondary Phone (Optional)
Physical Description of Person
Gender*
Race*
Race (Other) - Please Specify*
Age*
Height*
Weight (lbs)*
Eye Color*
Hair Color*
Method of Communication*
- Verbal
- Non-Verbal
Non-Verbal Methods of Communication*
- Sign Language
- Picture Board
- Written Words
Emergency Contact Information
Name of Parent or Guardian*
First Last
Address of Parent or Guardian*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Secondary Phone (Optional)
Additional Emergency Contact Information (Optional)
Additional Caregiver
First Last
Address
Street Address Address Line 2 City State ZIP Code
Primary Phone
Secondary Phone (Optional)
Additional Information (Optional)
Describe any unique or special behaviors or characteristics for this individual
Describe best approach for responders to use for this individual
Describe any sensory or medical needs for this individual
ID Wear: Jewelry, name on clothing, tattoos, etc
Photo Upload (Optional)
Accepted file types: jpg, gif, png, pdf, Max. file size: 1 MB.
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Email
This field is for validation purposes and should be left unchanged.

EFFORT: Special Needs Emergency Information Form

Special Needs Person Information

Physical Description of Person

Emergency Contact Information

Additional Emergency Contact Information (Optional)

Additional Information (Optional)