Autism Alert Form

   
Please enter the first and last name of the individual
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Please select the birth month, date, and year for the individual
Please select an option
Please enter the street address of the individual
Please enter the individual's height
Please enter the individual's weight in pounds using whole numbers only
Please enter the individual's skin color
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Please enter the individual's hair color
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Please enter any methods of communication used by the individual
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School Information:

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Please enter a valid phone number (123-456-7890)
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Medical Care Provider:

Please enter the name of the medical care provider
Please enter a valid phone number (123-456-7890)

Caregiver Information:

Please enter the parent or caregiver's name
Please specify the relationship to the individual (parent, caregiver, etc)
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Please enter a valid phone number (123-456-7890)
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Invalid Input - Please enter a valid email address
Please enter a valid phone number (123-456-7890)
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Emergency Contact:

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Please enter a valid phone number (123-456-7890)
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Invalid Input - Please select Yes or No
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Invalid Input - Please enter a valid phone number (123-456-7890)
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Other Important Information:

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Survey Question:

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