Residential ADA Disability | Medina County Sheriff's Office

URL

This field is for validation purposes and should be left unchanged.

1. Contact Information (Self, Parent, Caregiver, or Agency)

Name*

First Last

Age*

Gender*

Address*

Street Address Address Line 2 City State ZIP Code

Want to add an additional contact*

Yes

Name

First Last

Age

Gender

Address

Street Address Address Line 2 City State ZIP Code

2. Emergency Contact:

Name*

First Last

Relationship*

Address*

Street Address Address Line 2 City State ZIP Code

Home phone

Work phone*

Cell Phone*

3. Does any member of your household have a disability/medical condition?

Name*

First Last

Age*

DOB*

Race*

Height*

Weight*

Eye color*

Hair color*

Scars/identifying marks

Check all that apply*

List others

Want to add another household member?*

Yes

Name*

First Last

Age*

DOB*

Race*

Height*

Weight*

Eye color*

Hair color*

Scars/identifying marks

Check all that apply*

List others

4. How many household members?

4. How many household members?*

5. Is the person with a disability in your household likely to wander off?

5. Is the person with a disability in your household likely to wander off?*

Yes

6. Fill out the following and identify the person(s) to whom it is applicable:

Favorite attraction or locations where they may be found:

Atypical behaviors or characteristics that may attract attention:

Favorite toys, objects or discussion topics (likes, dislikes):

Approach, calming or de-escalation techniques most likely to work:

Method of communication, if nonverbal, i.e. sign language, picture board, written words:

Identification information: Do they carry or wear identifying jewelry, tags, ID card etc.:

Sensory or dietary issues, if any:

Please use the space below to provide any additional information you feel that the Medina Safety Departments should be aware of in order to more effectively respond to an emergency situation in your household.

Is there a key holder to your property or someone to be notified in case of an emergency?*

Yes

Name

First Last

Phone

IMPORTANT: By signing this form, I acknowledge that the information provided above was done so voluntarily for the sole purpose of assisting the Medina County Sheriff’s Office, through their emergency dispatch center and to their emergency response personnel, to more effectively respond to a potential emergency in or near my household.

I also understand that providing this information does not entitle me or anyone in my household to preferential treatment, nor will it result in a timelier response by emergency response personnel. It is simply an attempt to provide emergency response personnel with information, which may be helpful when providing service to residents or occupants of my home.

Are there more than one heads of household?*

Yes

Signature Head(s) of Household*

Date*

Signature Head(s) of Household*

Date*

Medina County Sheriff's Office

Residential ADA Disability Form

Residential ADA Disability Form

1. Contact Information (Self, Parent, Caregiver, or Agency)

2. Emergency Contact:

3. Does any member of your household have a disability/medical condition?

4. How many household members?

5. Is the person with a disability in your household likely to wander off?

6. Fill out the following and identify the person(s) to whom it is applicable: