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This form is meant for community members to submit on behalf of a child, dependent adult, or themselves detailing special considerations law enforcement should take upon contact with that individual. This information will be used to by deputies to formulate a specialized response should the individual need to be contacted during a law enforcement investigation.
Please include as much detail as possible.
Please list all relevant medical conditions. This information will be kept confidential and will only be used to inform law enforcement response.
If non-verbal: sign language, picture board, written board, etc.
Please include all information applicable.
By checking the box below, I acknowledge that I am providing the above information voluntarily and have the authority to do so. I understand the purpose of this form is to provide first responders with information and resources that will allow them to better serve individuals within our community affected by disabilities and mental illness. By submitting this form, it is understood that this information will be maintained by the Humboldt County Sheriff's Office for use when interacting with the subject described, I also understand that the information can be removed from our database at any time by submitting a written request to do so.
Enter your first and last name.
This field is not part of the form submission.
* indicates a required field