Forms • Perkins, OK • CivicEngage

The online registry promotes communication and gives police quick access to critical information about a registered person who has been diagnosed on the autism spectrum in a police emergency by capturing information such as a full description, routine/favorite attractions, communication and other special needs as well as emergency contact information.

Need more info?

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For further information, please call Perkins Police Department at (405) 547-2855.

For emergencies, please call 9-1-1

Is this a new form or a renewal form?*

New Form

Renewal Form

Full name of child or adult who has been diagnosed on the autism spectrum

Nickname

Year of birth

Weight

Height

Eye color

Hair color

Scars or identifying marks

Medical condition(s)

Street address

City

State

Zip

Mailing address (if different from street address)

Mailing address city (if different from street address)

Mailing address zip (if different from street address)

Home or cell phone of person being registered

Method of communication if non-verbal

Identification worn

Current prescription(s) (Include dosage)

Sensory, medical, or dietary issues and requirements, if any

Inclination for wandering behaviors or characteristics that may attract attention

Does person being registered engage in self-injurious stimming behavior?*

Yes

No

If person engages in self-injurious stimming behavior, please briefly describe

Favorite attractions and locations where the person being registered may be found if missing

Likes and dislikes

Daycare/school attending

Phone number for school/daycare

Medical care provider 1

Medical care provider 1 phone number

Medical care provider 2

Medical care provider 2 phone number

Medical care provider 3

Medical care provider 3 phone number

Parent/caregiver full name(s)

Parent/caregiver street address (if different from above)

Parent/caregiver city (if different from above)

Parent/caregiver state (if different from above)

Parent/caregiver zip code (if different from above)

Parent/caregiver cell phone(s) (if different from above)

Parent/caregiver work phone(s) (if different from above)

Parent/Caregiver email

Emergency contact #1 full name

Emergency contact #1 cell phone number

Emergency contact #2 full name

Emergency contact #2 cell phone number

Map and address guide to nearby properties with water sources and dangerous locations highlighted

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

Blueprint or drawing of home with the bedroom of the person being registered highlighted

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

Please provide us with a recent photo of the person being registered

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

In the event that the person being registered has been involved in an emergency incident, this information can be released to any of the following:

	Law enforcement
	School
	Media

	Social media
	First responders/EMS

* indicates required fields.

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