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Autism / Special Needs Outreach Form

  1. WMPD Autism Letterhead Logo
  2. This voluntary community registry is intended for people with Autism Spectrum Disorders (ASD) and is a Wilton Manors Police Department project in partnership with the City of Wilton Manors. The registry promotes communication and gives police quick access to critical information about a registered person with autism 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. To be truly effective, this form will require your permission to be shared with this jurisdictional law enforcement agency, which your child/dependent adult resides or is in on a regular basis. (i,e., for school, daycare, etc.). The information will be kept confidential and made available only to our patrol officers. **NOTE - A recent Photo will be required to be included with this application.

  3. Currently, individual registration is intended for those with Autism Spectrum Disorders (ASD); although, the registry has been developed with the intent to be expanded for all residents where communication is ineffective when interacting with police. This expansion will be considered upon completion of a formalized evaluation.

  5. * Indicates a Required Field
  6. Race*
  7. Relevant Medical Conditions in addition to Autism
  10. The person filling out this form is the:*
    **If Other, Please provide additional contact information below.
  11. * I understand this is a voluntary registry program, and I attest the information provided herein is truthful and accurate. I understand if any information changes or if the registrant no longer resides in the City of Wilton Manors I shall contact the Wilton Manors Police Department without delay and notify them. Furthermore, I understand this registration is valid for one (1) year and I must re-register annually to remain in this program. *
  12. Leave This Blank:

  13. This field is not part of the form submission.