2. 
4. Student Name:
5. Age / DOB:
6. Grade:
8. Home Address:
9. Student Cell:
11. Parent/Guardian 1 address, if different from student:
13. Parent/Guardian 2 address, if different from student:
15. Parent/Guardian 1 Telephone #:
16. Home:
17. Cell:
19. Parent/Guardian 2 Telephone #:
20. Home:
21. Cell:
23. Emergency Contact name/contact #'s
25. Student's disability/diagnosis:
27. Student attends (name of school):
29. Student is VERBAL:

    1. Yes
    2. No
31. Student is:

    1. Deaf
    2. Hard of Hearing
33. Allergies:

    1. Yes
    2. No
35. If Yes to Allergies please explain:
37. Medications (optional):
39. Student has following behaviors (please describe):
41. Student is afraid/Anxious around new people:

    1. Yes
    2. No
42. If Yes, Please explain:
44. Students reaction to unfamiliar people (please describe):
46. Student is afraid of animals:

    1. Yes
    2. No
47. If yes please explain:
49. Student may react to load noises (.e. sirens):

    1. Yes
    2. No
50. If yes, please explain:
52. Student is capable of being home without an adult:

    1. Yes
    2. No
54. Weapons/Firearms in home?

    1. Yes
    2. No
56. Due to the student's disability, he / she may (check all that apply or explain in other)

    1. Panic if yelled at, and lash out if touched or physically restrained
    2. Misinterpret things you tell me or ask me to do
    3. Not be able to answer your questions
    4. Appear not to be listening or paying attention
    5. Tend to interpret statements literally
    6. Appear rude or say things that sound tactless, especially when anxious or confused
    7. Have difficulty making eye contact
    8. Speak too loud, too soft, or with unusual intonation
58. Other:
60. Strategies that might help: (check all that apply or explain in other)

    1. Clearly identify yourself as a law enforcement officer/first responder
    2. Call one of my emergency contacts
    3. Do not assume that traits of the student's disability constitute suspicious behavior
    4. Avoid touching or restraining the individual unless absolutely necessary
    5. Speak to me in normal, calm, non confrontational tones
    6. Tell the individual what he/she needs to do as politely, clearly, simply, literally, as possible and in small step-by-step directions
62. Other: ( i.e. favorite places to visit, toys, likes etc.)
64. Photo of student attached:

    1. Yes
    2. No
66. Use school photo/ID:

    1. Yes
    2. No
68. Photo may be submitted via email to: Detective Caroline Paladino at cpaladino@concordma.gov or Detective Derek Rodriguez at drodriguez@concordma.gov.
70. Submitted by:
71. Title:
73. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
75. Electronic Signature

77. With any questions please contact either: Detective Caroline Paladino (cpaladino@concordma.gov) or Detective Derek Rodriguez (drodriguez@concordma.gov) Concord Police Department or Frances Wooff, Director of Special Education at fwooff@concordps.org

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79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

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