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

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

  2. Diagnosis

    (may choose more than one)

  3. Language Understood:

    (may choose more than one)

  4. Communication

    (may choose more than one)

  5. Fears & Sensitivities

    (may choose more than one)

  6. Behaviors, Qualities, Attractions and Interests

    (may choose more than one)

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

  8. Relationship

  9. Requesting*

  10. Leave This Blank:

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