Autism

North Arlington Police Department

214 Ridge Rd, North Arlington, NJ 07031

Phone: 201-991-4400 ext. 0

Fax: 201-991-4068

Safely Back Home Enrollment Form

Thank you for taking the initiative to be a part of the North Arlington Safely Back Home Program

Safely Back Home™ is an innovative program that provides additional peace of mind to families and caregivers of people who wander. The Safely Back Home™ patent-pending process uses ID information imprinted on personal garments to help the public and the police assist an individual who has become lost.

The Safely Back Home™ Program was developed in response to a need to provide assistance to individuals who are incapable of providing identifying information in situations where they become lost.

When an individual who wanders and appears lost is wearing a Safely Back Home™ imprinted garment, the concerned person who notices them can quickly contact NAPD with location details and a rescue ensues.

The Safely Back Home™ program enables police and first responders to understand how to communicate effectively with your family member, allowing your family member to remain calm during their rescue.

Families/Caregivers provide medical and personal information about the family member. All information remains confidential and privacy protected. Wherever your family member is wandering (in NJ/USA) – police departments are able to electronically share this information in coordinating the rescue.

Applicant Information

The enrollment application should be filled out by the family member/caregiver (the Authorized Representative) on behalf of the individual (the Applicant) who will be enrolled in the NAPD Safely Back Home program. Providing this detailed information in advance of any need ensures an efficient and speedy response by Emergency Services personnel. Please be as thorough and complete as possible.

Please provide a current PHOTO of APPLICANT here

Upon receipt and review of the enrollment application, a NAPD Safely Back Home ID number specific only to the applicant will be issued. The family member/caregiver will receive this NAPD Safely Back Home ID# via email. The family member/caregiver will also receive notification that the application has been accepted.

IMPORTANT: All information submitted on the enrollment form will be kept confidential and stored in a secure database maintained by the NAPD.

This application is divided into Three sections:
• The first section requires information about you, the Authorized Representative.
• The second section is for additional emergency contact information. Should you not be
available or if we are unable to get in touch with you, only an authorized person(s) listed on the
enrollment form will be contacted.
• The third and last section of the application is where you will provide information about the
individual being enrolled, the Applicant. All sections are to be filled out by you, the Authorized
Representative.

APPLICANT’S NAPD-SBH ID#

THIS NUMBER WILL BE PROVIDED TO AUTHORIZED REPRESENTATIVES FROM SAFELY BACK

HOME (SBH) TO BE USED AND PRINTED ON SBH GARMENTS/ATTIRE TO ASSIST THE

APPLICANT IN BEING RESCUED AND RETURNED TO THEIR FAMILIES.

APPLICANT’S NAME

M F

Section 1: Authorized Representative Information (PRIMARY CONTACT)

Section 2: Secondary Emergency Contact Information

If an emergency arises and we are unable to reach the authorized representative, we will contact the individual(s) you designate below. Please provide contact information for two additional people that the NAPD may contact..

Section 3: Applicant’s Information - Personal Data

Male Female

Is the Applicant Verbal or None-Verbal ? Verbal None-Verbal

Does the Applicant live alone? Yes No

Does the Applicant understand English? Yes No

If NO, what language is understood?

Spoken word only Written and spoken Sign Language

Physical Description

Medical Diagnosis

Applicant’s specific diagnosis?

If the applicant wears corrective eye wear, what degree of vision does he/she have without the eye wear? None Poor Fair

Does the Applicant wear a hearing aid? Yes No If yes, Left Ear Right Ear

What type of hearing does he/she have without the hearing aid? None Poor Fair

Does APPLICANT have any ALLERGIES to medication/food? Yes No

If yes, please list those allergies to medication/food:

None

Health/Behavioral Information

Health, medical, or related physical handicap issues?

Please list medications taken regularly: None

Does the Applicant know his/her name? Yes No

Will applicant respond if called by his/her name? Yes No

Would the Applicant attempt to or have the ability to communicate if lost or hurt? Yes No

How would he/she do this?

How would you rate the Applicant’s overall ability to communicate?
Poor Fair Good Excellent

What name does the Applicant call the family member or friend with whom they have the closest
emotional attachment?

Does the Applicant recognize familiar persons and faces? Yes No

Does the Applicant have a fear of people, pets / animals, noises, shouting; anything else?

Do you have any suggestions for what the First Responder/Police Officer should say to the Applicant to help keep him/her calm as the First Responder/Police Officer approaches them?

Method of Preferred Communication One (If verbal: preferred phrases, words, sounds, songs they respond to):

Method of Preferred Communication Two (If nonverbal: Sign Language, written words, picture boards, etc.):

How will the Applicant react if approached by a uniformed officer?

Can the Applicant travel on his/her own to familiar or favorite locations?
Yes No

List favorite attractions or locations where the Applicant may be found:

Personality/Habits

Applicant’s favorite objects, music, TV shows/characters, sports teams/players, discussion topics, likes or dislikes:

Items applicant would carry/wear that provide comfort or may have a sentimental value (Example: photos, cell phone, book, favorite hat or other object that provides comfort to them.)

Explain:

When outside, would the Applicant mostly stay on roadways? Yes No

Does the Applicant drive a car? Yes No

If so, what is the:

Would the Applicant wander to parks/go into wooded areas? Yes No

Would the Applicant most likely wander during the: Day Night Both

Please provide the names and addresses of people the Applicant may head toward:
1.
2.
3.
4.

Are there any locations that have a special or significant attraction to the Applicant? Yes No

Please list most recent locations:

If there were any prior instances of wandering, where was the Applicant found?:
Location:

General Demeanor: Outgoing Quiet

Talks to strangers: Yes No

Identification Information. (Does the Applicant carry or wear jewelry, tags, ID card, medical alert bracelets, etc?):
Please explain:

Tracking Information (Does the Applicant have a Project Lifesaver number or other tracking device number?): Yes No
If yes, please enter the Project Lifesaver ID number or other tracking device number:

Release

I, the undersigned, for myself and on behalf of the Applicant named above, do hereby authorize the North Arlington Police Department to release the above information in response to emergency calls regarding the Applicant and do further agree to indemnify and hold harmless the North
Arlington Police Department, Safely Back Home, and its respective employees, agents, officers and directors from any and all claims (other than willful misconduct) arising out of participation in the North Arlington Police Department Safely Back Home program or the release of the above information.
Furthermore, I hereby represent and warrant to the North Arlington Police Department and Safely Back Home that I have full power and authority, as the duly authorized representative of the Applicant named above, to enroll and act on his or her behalf.

Authorized Representative signature (Typed)

Date: