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Manhattan Beach Police Department
Resident’s Safety Form
(For MB Residents and MBUSD Students with Disabilities)
PHOTO HERE
Date Application Submitted:___________________
Name:______________________ DOB:___________ Disability:_____________ Street Address:___________________________________
City:_______________________________
Home Phone:_________________
Cell Phone:_____________
Physical Description: Sex:______Race:______Weight________Height:________ Eyes:_____ Hair_______ Distinguishing physical characteristics _________ Parent/Guardian Name and Phone Number:__________________________ (Conservator? Yes No )
Parent/Guardian Name and Phone Number:_________________________ Other Contact: Name___________Phone:___________Relationship____________ Other Contact: Name___________Phone:____________Relationship____________ Advice and Things to Know:
Verbal Communication: Yes No Things to know: ________________ Key Phrases for communication: ________________
Behavior Triggers: ___________________
Calming objects or phrases: ____________________
Favorite Discussion Topics for Calming/Connecting: ___________________ Eloping Risk: Yes No Favorite Places To Go:____________________ Relevant Medical Conditions for First Responders to Know:___________________ Doctor’s Information:
Name:___________________________Phone:_________________________________ MBUSD School Name (If Applicable):_____________________ Best Staff Contact:_______________ Phone:__________________
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