Persons With Disability Information Program

Child's / Residents Vital Statistics

Full Name *

Nickname (if any)

Primary Diagnosis *

Street Address (Apt./Unit if applicable) *

City / State / Zip Code *

Sex *

Male

Female

Race (White/Black/Hispanic/Asian)

Height

Weight

Hair Color

Eye Color

Distinguishable Marks (Scars, Birthmarks, etc.)

ID / Medical Alert Jewelry, etc.

A Recent HEAD SHOT Portrait

A Recent FULL BODY Picture

Emergency Contact Information

Mother’s (or Guardian) Name

Phone Number

Father’s (or Guardian) Name

Phone Number

Alternate Contact #1 Name

Phone Number

School Name

School Phone Number

Doctor’s Name

Doctor’s Phone

Signature (Type Full Name) *

As the legal parent/guardian/ self of the individual listed on page 1 of this form, I hereby authorize the release of my child/relative’s personal information to the Doylestown Township Police Department to be kept on file and utilized by the police and/or other emergency responders in the event of an emergency. The information will be kept confidential and can be removed at any time.

Today's Date *

Month

Day

Year

Leave this field blank