Waukesha County Public Safety - Person specific Info for First Responders

WAUKESHA COUNTY

PERSON SPECIFIC INFORMATION FOR FIRST RESPONDERS
In response to the needs of individuals living with disabilities and health challenges in Waukesha County, we recognize the importance of equipping our first responders—including Police, Fire, EMS, and 911 Dispatchers—with essential information to enhance their preparedness and effectiveness. To this end, a comprehensive, universal fillable form has been developed for use by all agencies within Waukesha County. By providing advanced medical and behavioral information, this tool facilitates improved understanding and more accurate situational assessments, leading to more appropriate responses in emergency scenarios.
Individual's Information
Individual's Name :*

First NameMiddle NameLast Name
Date of Birth :*

MonthDayYear
Date Submitted :*

MonthDayYear
Address :*

Street Address

Street Address Line 2

CityState / Province

Zip Code
Municipality of Residence*

Individual's Current Physical Description
Gender :*

MaleFemaleOther
Height :*
Weight :*
Eye Color :*
Hair Color :*
Scars or other identifying marks :*
Upload Photo :*

Browse Files
Please upload a current photo of the individual Cancelof

Emergency Contact Information
Name of Emergency Contact (Parent/Guardian or Care Provider) :*

First NameLast Name
Emergency Contact's Address :*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Email Address :
matthew@example.com
Emergency Contact Phone Numbers :
Home :*
Work :
Cell Phone :*
TDD/TTY :
Alternate Emergency Contact Information
Name of Alternate Emergency Contact :

First NameLast Name
Alternate Emergency Contact Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Emergency Contact Email Address:
example@example.com
Alternate Emergency Contact's Phone Numbers :
Home :
Work :
Cell Phone :
TDD/TTY :

Information Specific to the Individual
Favorite attractions or locations where the individual may be found (If none type N/A or None):
Atypical behaviors or characteristics of the Individual that may attract the attention of responders (If none type N/A or None):
Individual’s favorite toys, objects, discussion topics, likes, or dislikes (If none type N/A or None):
Method of Preferred Communication (If none type N/A or None):
(If nonverbal: Sign language, picture boards, written words, etc. If verbal: Preferred words, sounds, songs or phrases the individual may respond to)
Identification Information - Does the individual carry or wear jewelry, tags, ID card, medical alert bracelets, etc.? Where are these located? (If none type N/A or None):
Responding to this form is voluntary. This form can be filled out by the individual living with the specified health challenge or disability, their parent/guardian (in the case of a minor), assigned caregiver, or recognized representative. If an individual or their representative chooses to use this form, they must provide their signature below listing their Name/Relationship. In addition, this information may be removed from files periodically (every 2 years) per our process for Special Situations requests. Therefore, it is recommended that individuals or their representatives update and submit this form at least every 2 years to ensure that files are kept updated and accurate.

Please be aware: The information provided on this form will assist police, fire, or emergency response personnel ONLY when they are responding to an emergency or other call from your home, for purposes of identifying and/or assisting you or another individual in your household who is living with a disability or health challenge.
Information about Person Completing this Form
Name of Person Completing this Form :*

First NameLast Name
Email Address of Person Completing this Form:*
matthew@example.com
Relationship to the Individual:*
Alternate Contact Name/Relationship :
By completing this form, I acknowledge that the information provided herein is accurate and was submitted voluntarily for the sole purpose of assisting Police, Fire, and Emergency Response Departments in more effectively responding to a potential emergency in or near my household. I authorize the use of this information for those purposes and waive any claim in law and equity against Waukesha County, it's officers, agents and employees, which I, {nameOf108}, or any of our representatives, descendants, successors, and/or assigns might otherwise have arising from or related to the use or existence of the information provided herein. I understand that the information used or disclosed may be subject to re-disclosure and no longer protected by State or Federal privacy standards. I further understand that providing the information on this form does not entitle me or anyone in my household, including {campersName4}, to preferential treatment, including a more timely response by emergency response personnel.
Signature :*

Clear
Date

MonthDayYear
Please verify that you are not a Robot*

OFFICIAL USE ONLY
Name of Officer/Clerk/Dispatch Personnel taking the info :
PSSA member that input this to CAD :
Expiration Date of Alert in CAD (mm/dd/yyyy) :

MonthDayYear
Date
Should be Empty:

WAUKESHA COUNTY

Individual's Information