ENROLLMENT APPLICATION For 911 REGISTRY and PROJECT LIFESAVER OF ORANGE COUNTY NEW YORK

2. Applicants Name*

3. Nickname(s)

5. Date of Birth
   Date of Birth

6. Gender
   -- Select One --MaleFemaleTransgender

7. Applicant Lives with
   -- Select One --FamilyPaid Caregiver

9. Description of Applicant

   (height, weight, eye color, hair color, distinguishing scars, birth marks, tattoos)

11. Diagnosis

    (may choose more than one)

    1. Autism
    2. Alzeheimer's
    3. Brain Injury

    1. Cerebral Palsy
    2. Deaf
    3. Down Syndrome

    1. Epilepsy
    2. Intellectual Disability

    1. Mental health issues
    2. Other
13. Other diagnosis

15. Language Understood:

    (may choose more than one)

    1. English

    1. Spanish
16. Other languages understood

18. Communication

    (may choose more than one)

    1. Conversational Speech
    2. Gestures/Leads by Hands

    1. Limited Vocal Repertoire
    2. Non-Verbal

    1. Points to Pictures
    2. Sign Language

    1. Uses a Device
    2. Other
20. Other communication (describe)

22. Fears & Sensitivities

    (may choose more than one)

    1. Crowds
    2. Dogs

    1. Flashing Lights
    2. Loud Noises

    1. Touch

    1. Other
24. Other fears & sensitivities (describe)

26. Behaviors, Qualities, Attractions and Interests

    (may choose more than one)

    1. May enter surrounding homes/property
    2. Attracted to water
    3. No awareness of danger/safety
    4. Attracted to trains

    1. May repeat what you say
    2. May be non-responsive
    3. May hide
    4. May not follow directions

    1. May hit, slap, bite, kick, punch self or others
    2. May rock, cover ears
    3. Perseverates on words or scripts from movie/TV

    1. May bolt away
    2. May yell, shout, flail arms
    3. Other
28. Other: (describe)

30. Likes to talk about or play with

32. Applicant Physical/Medical Issues

34. Medication taken for

36. Allergies/Reactions

38. Individuals the Applicant May Attempt to Contact if Lost/Wandering

40. Name

41. Relationship to Applicant

43. Address

44. Phone

46. Name

47. Relationship to Applicant

49. Address

50. Phone

52. Primary Caregiver(s) Name

54. Relationship

    1. Parent
    2. Adult Sibling

    1. Adult Child
    2. Other

55. Other relationship

57. Street Address (No P.O. Boxes)

59. Ext (Apt. Complex/Bldg/Apt.#)

61. City

62. Zip Code

63. Residence Phone

65. Cell Phone

66. Email

68. Requesting*

    1. 911 Registry ONLY

    1. Project Lifesaver Registry (includes 911 registry)

70. Project Lifesaver Registry
    Next Step

    Click here to complete the registration form for Project Lifesaver. Both forms must be submitted to complete your application.

72. Approval

    1. Approved

    1. Denied

73. Date Approved/Denied
    Date Approved/Denied

75. Frequency # Assigned

    Only if Approved

76. Reason Denied

    Only if denied

78. Qualifies for Free Kit

    1. Yes
    2. No

79. Type of Payment Rcvd.
    -- Select One --CashCertified CheckMoney Order

80. Date Pmt. Rcvd.
    Date Pmt. Rcvd.

82. Appointment Date Schedule for Kit Pickup/Orientation

83. Date Approved Application Submitted to Sheriffs Dept. for entry to PLI Database

85. Pending, Additional Information Needed

    1. Missing Photo Image
    2. Criteria Not Met

    1. Legal Authority Needed

    1. Schedule of Supervision Not Completed

    1. Application Not Completed

Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit Submit and Print

* indicates a required field