Autism Action Initiative Registration Form

Provided by Center Township Trustee Jesse Harper, Valparaiso Police Department, Porter County Sheriff’s Office, Valparaiso Community Schools, Valparaiso Fire Department, Valparaiso YMCA, and Porter County 911
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Individual Information

Your Name
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Enrolled in Smart911

Physical Description

Behavior Traits

Fight/Flight Risk?
Responds to Name?
Eye Contact?
Impaired sense of danger?
Responds to verbal commands?

As the parent(s)/guardian(s) of the Child named above, I/we consent to the release of the information contained herein to the Center Township Trustee’s Office, Valparaiso Community Schools, and first responder personnel, including but not limited to the Porter Coumnty Sheriff’s Office, Valparaiso Police Department, Valparaiso Fire Department, and Porter County Central Communications (911 Dispatch). I/we also agree to hold harmless and release all liability from the Center Township Trustee’s Office along with its employees, agents, and representatives from any and all damages, claims, injuries or other actions resulting from our participatin in the Autism Action Initiative Registration program.