Special Family Member Directory

What is the SPECIAL FAMILY MEMBER DIRECTORY?

The Special Family Member Directory is a project in partnership between you, as the community members of the City of Eastlake and the Eastlake Police Department. This online directory promotes communication and enables the police department to have quick and relevant access to important information about a person with a Special Need. This information may be crucial in instances where affected persons wander or are experiencing a crisis situation.
The information submitted about the person may include: name, birthday, physical description, emergency contact information, known triggers/behaviors and more. Having early access to this information may prove crucial to successfully defusing a crisis situation or locating a person that has wandered away from safe surroundings.

Goal of the Program

The goal is to help ensure the safety of individuals with developmental disabilities. Also included in this Directory would be individuals with Alzheimer’s disease and dementia. We want to bring your loved ones safely back home. THIS ROSTER IS CONFIDENTIAL AND AVAILABLE ONLY TO THE POLICE DEPARTMENT.

How to Register

To register your family member, an adult family member — or the guardian of an individual with a developmental disability or dementia — must complete and submit the online form (below).

What happens once the person is registered?

Once the person is registered, their information will be placed into a searchable database in the City of Eastlake Police Department’s record management system. This information will then be available to the officers responding to a call for help or assistance with your Special Family Member. When possible, a specially trained, “Crisis Intervention Team” (CIT) officer will be sent to the scene.

Register Annually

The information must be updated and submitted each year to ensure the information is accurate and up to date.

Step 1 of 12

Person Completing This Form

First name*
Last name*
E-mail*
Phone*
Relationship to Special Family Member*

Step 2 of 12

Special Family Member

Full name*
Date of Birth*
Select EEOC Category*
Gender*
Height*
Weight*
Hair/Color*
Eye Color*
Scars/Birthmarks/Tattoos

Step 3 of 12

Special Family Member Residential Information

Home Address*
City*
Zip Code*

Step 4 of 12

Parent or Guardian Information

Name of Parent/Guardian*
Primary Phone*
Secondary Phone
Place of Work
Work Address
Name of Other Parent/Guardian
Primary Phone
Secondary Phone
Place of Work
Work Address

Step 5 of 12

Symptomatology

Primary Diagnosis*
Co-existing Diagnosis
Communication*
Describe Communication if Non-Verbal

Step 6 of 12

Wandering

Prior Wandering Incident*
If "Yes," Is There A Place He/She Has Been Found Before?
Closest Water to Residence
Favorite Hiding Place at Home (if applicable)
Favorite Hiding Place in Neighborhood/Community (if applicable)
Respond to Name Being Called?*

Step 7 of 12

Characteristics

Select Sensory Issues*
Select Touch*
Select Sounds*
Select Bright Lights*
Self-stimulatory (Stimming) behavior*
Process Delays?*
Fears
Dislikes/Triggers
Favorite Objects/ Topics
Pre-meltdown Signs
Meltdown Behavior
Calming strategies that work
Physical aggression or prior contact with the police
Weapons in the home?*
Are weapons properly secured?*
Alcohol/Drug Issues?*
Does the Family Have a Crisis Action Plan?*

Step 8 of 12

Emergency Contact Information

Name of the Primary Emergency Contact
Relationship
Address
City
Primary Phone Number
Secondary Phone Number

Step 9 of 12

Other Contact

Case Worker Name
Case Worker Phone Number
Case Worker Agency
Case Worker Agency Phone

School Contact

School Name
School Grade
School Address
School Contact
School Contact Phone

Step 10 of 12

Vehicle Information

Vehicle make, model and year
Vehicle color
Vehicle license plate number

Step 11 of 12

Additional Information

Choose File

Attach a recent photograph... Upload a current photograph that only has the person you are submitting for in the picture. (Required)

Add any additional information

Step 12 of 12

Release & Submit

RELEASE OF INFORMATION I, hereby give my permission for any first responder agency (including but not limited to police, fire/rescue/EMS/911 dispatch center, search and rescue personnel) to retain and distribute the information contained in this registration form to other first responder personnel for the sole purpose of identification and protection of the person identified above in an emergency or crisis situation. By typing your name in the box, you are agreeing to the release terms posted above.

Enter Your Full Name*
Enter Today's Date*

City of Eastlake Ohio