S.A.Id. Participation Form

If you are a parent, guardian, caregiver or individual with medically diagnosed special needs, please complete the following form to participate in the program. Answer all questions completely and accurately, as this information will be utilized to create the alert in our database. If you have a question regarding any portion of the form, send an email to wayne.pruitt@salina.org and amber.pfeifer@salina.org.

Please provide information on the individual who will have the S.A.Id. Alert

Nickname/Name the Individual Responds to:

Cell Phone Number

Cell Phone Provider

Additional Phone Number

Email Address

Descriptive Information

Race

Height

Weight

Hair Color

Eye Color

Please list any physical identifiers (scars, marks, tattoos, physical conditions)

Please provide vehicle information on the individual who will have the S.A.Id. Alert

Make

Model

Year

Color

Tag number

Photo

Please upload a recent photo of the individual that includes only their head and shoulders. If possible, also send a digital version of the photo (png or jpeg format) to wayne.pruitt@salina.org and amber.pfeifer@salina.org. Make sure to include the individual's name and date of birth in the email.

Upload Photo

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What upsets this individual?

What is their safety item or something that calms them down?

If they are known to wander, what is their favorite place or a common hiding place outside of the home?

School or Daycare Information (if applicable)

Name of School or Daycare

Phone Number of School or Daycare

Primary Emergency Contact

Relationship

Cell Phone Number

Cell Phone Provider

Additional Telephone Number

Email Address

Secondary Emergency Contact

Relationship

Cell Phone Number

Cell Phone Provider

Additional Phone Number

Email Address

S.A.Id. Participation Form completed by:

First Name

Last Name

By submitting this form, I certify that the information provided is true and accurate to the best of my knowledge. I understand that I voluntarily provided the information listed within this form and that it will not result in any type of preferential treatment from first responders. I hereby grant the Salina Police Department to create an alert utilizing the above information and consent to that information being shared with the Salina Fire Department and the paramedics and ambulance service.

Authorization for Alert

I agree

City of Salina

S.A.Id. Participation Form

Please provide information on the individual who will have the S.A.Id. Alert

Descriptive Information

Please provide vehicle information on the individual who will have the S.A.Id. Alert

Individual's Special Needs

School or Daycare Information (if applicable)

Primary Emergency Contact

Secondary Emergency Contact