[City of Manhattan Beach] Manhattan Beach Police Department Resident’s Safety Form

Section 1 of 1 in this document

Manhattan Beach Police Department Emergency Identification Registration

(For MB Residents and MBUSD Students with Disabilities)

The purpose of this form is to assist MBPD officers with additonal information for individuals in our community with disabilities. The information provided below will help inform our officers of the individual's disabilities and help them proceed with the approproiate course of action.

Relationship to the Participant (i.e. Parent, Guardian, Spouse, Teacher, Self, etc.)

INFORMATION ABOUT THE PARTICIPANT

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HOME PHONE NUMBER

CELL PHONE NUMBER

PHYSICAL DESCRIPTION

Sex

Race:

Weight:

Height:

Eye Color:

Hair Color:

DISTINGUISHING PHYSICAL CHARACTERISTICS (including scars, tattoos, wears glasses, etc.

ADVICE AND THINGS TO KNOW ABOUT THIS INDIVIDUAL:

VERBAL COMMUNICATION

Yes

THINGS TO KNOW REGARDING VERBAL COMMUNICATION

KEY PHRASES FOR COMMUNICATION

BEHAVIOR TRIGGERS

CALMING OBJECTS OR PHRASES

FAVORITE DISCUSSION TOPICS FOR CALMING/CONNECTING

FLIGHT RISK

Yes

FAVORITE PLACES TO GO

RELEVANT MEDICAL CONDITIONS FOR FIRST RESPONDERS TO KNOW

DOCTOR’S INFORMATION

Name

Phone

MBUSD SCHOOL NAME

BEST MBUSD SCHOOL CONTACT

Name

Phone

PARENT/GUARDIAN INFORMATION

HOME PHONE NUMBER

CELL PHONE NUMBER

CONSERVATOR?

YES

OTHER CONTACT INDIVIDUALS

NAME

PHONE

RELATIONSHIP

NAME

PHONE

RELATIONSHIP

I request and give permission to the Manhattan Beach Police Department to enter the above-listed dependent individual information into their internal and secure Records Management System. This allows Manhattan Beach Police officers working on patrol to access this information in the event my loved one wanders away or goes missing. All information submitted will be secured on an internal server and used solely for police operations.

It is the responsibility of the family to keep this information current. When applicable, please submit a new form with updated personal information, physical attributes, and diagnoses.

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.