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2. PERSON BEING REGISTERED:
4. First Name*
5. Last Name*
7. Date of Birth*
   Date of Birth
8. Photo of person being registered*
10. Address*
12. City*
13. State*
14. Zip Code*
16. Phone Number*
17. Gender*
    -- Select One --MaleFemale
19. Weight*
20. Height*
22. Eye Color*
23. Hair Color*
25. Language(s) Spoken*
26. Race/Ethnicity*
28. Complexion*
    -- Select One --FairMediumDark
30. Regularly Wears*

    1. Glasses
    2. Contact Lenses

    1. Wigs
    2. Hearing Aids

    1. Other
    2. None
32. Registrant has*

    1. Beard
    2. Mustache
    3. Scars

    1. Tattoos
    2. Birthmarks

    1. Other
    2. None
34. Description of features checked above*
38. CARETAKER/PARENT INFORMATION
40. Name*
41. Relationship to person being registered*
43. Address*
45. City*
46. State*
47. Zip Code*
49. Phone Number*
50. Alternate Phone Number
54. ADDITIONAL CONTACT PERSON
56. Name
57. Relationship to person being registered
59. Address
61. City
62. State
63. Zip Code
65. Phone Number
66. Alternate Phone Number
70. ADDITIONAL INFORMATION REGARDING PERSON BEING REGISTERED
72. What are their favorite objects, toys, music, discussion topics, likes or dislikes?*
74. How do they communicate? Are they non-verbal?*
76. What type(s) of behavior should be expected (kicking, hitting, biting, spitting, self-hitting, body rocking, hand flopping, self-talking)?*
78. What is the best way to approach them?*
80. Do they have any triggers or sensitivities (i.e. lights, sirens, loud noises, etc.)? *

    If yes, please explain.

82. If they become confrontational, how can officers calm them? What works best to reduce stress for them?*
84. Additional Information

    Detail any information you feel may be important.

88. Release

    I, the undersigned, for myself and the registrant named above do hereby authorize the Chino Police Department to release the aforementioned information in response to emergency calls (including missing persons) regarding the registrant and do further agree indemnify and hold harmless the Chino Police Department and the persons (placed) associated with it. 

90. By checking this box and typing my name below, I am electronically signing my application.*

    1. I agree
92. Signature of Caregiver*
Leave This Blank:


94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit

* indicates a required field