by Lieutenant Craig Denman
4/4/2015

Our program is modelled on programs created by other law enforcement agencies in response to a common tendency for individuals with autism or Alzheimer’s disease to wander off from their safe environment. The aim of our program is to create a database of resident information that would be available to all of our officers. Not only can this help us return a resident home safely in the event that they do wander off, but it can help us to respond appropriately in our encounters with any of our special needs residents.

Examples of residents who might benefit from this program include but are not limited to:

• Children or adults with autism
• Adults with dementia or Alzheimer’s Disease
• Children or adults that use a wheelchair or other mobility device
• Children of adults who are non-verbal
• Children or adults with Down’s Syndrome

The Town of Holliston is a close knit community and we pride ourselves on our involvement in the community. The members of the Holliston Police Department support and embrace this culture. Our officers are present in the schools, at holiday strolls, at events such as Celebrate Holliston and we are customers at local businesses. We are a part of your community and we take pride in personally knowing each resident we encounter.

If you are interested in providing information on your special needs family member, please complete the C.A.R.E. Form, the C.A.R.E. Questionnaire and the C.A.R.E. Release Waiver and return them to the Holliston Police Department. We will input your information into the database.

Thank you for allowing us to serve you and your family.

The forms, shown below, are available on line at http://www.hollistonpolice.com/Online%20Forms.htm

 

C.A.R.E. Program Release Waiver

Date: ______________     

 

I, ________________________________currently residing at _____________________________________­

   (print full and residential

address)                                                                                                                                                                                                                           

give permission to the Holliston Police Department to release any and all information related to the care or

well-being of ____________________________ to other law enforcement agencies and emergency services.

                                           (c.a.r.e participant name)                                                                                                                       

 

                          

     ____________________________________________                                ______________

                                        Signature                                                                                                     Date

 

 

 

            ____________________________________________                                ______________

                                       Officer Signature                                                                                        Date

 

 

 

Children And Resident Encounter Program Informational Form

 

Date: ______________                                                                                   CARE ID#: ______________

name [last, first, m.i.]	nickname:
current address:	DOB:
special interests:
verbal / non-verbal:	diagnosis:
caregiver #1:	caregiver #1 phone:
caregiver #2:	caregiver #2 phone:
calming tactics:

 

 

C.A.R.E. Program

 

Children and Resident Encounter Questionnaire

 

 

Date: ______________                                                                                        

 

1. C.A.R.E. Participant Name:  ________________________________________________________

(last name)                                    (first name)                                    (M.I.)

 

1. What is an address that he/she spends a majority of their time at? __________________

______________________________________________________________________________

1. Does he/she have a nickname? If so, what? ___________________________________________
2. What is his/her date of birth? __________________________                 Age: __________________
3. Please indicate diagnosis of C.A.R.E. Participant: ______________________________________

______________________________________________________________________________

1. List all pertinent names and contact numbers that patrol officers may need when assisting him/her:

 

Name: ____________________             Relationship: _________________     Phone #: _____________

Name: ____________________             Relationship: _________________     Phone #: _____________

Name: ____________________             Relationship: _________________     Phone #: _____________

Name: ____________________             Relationship: _________________     Phone #: _____________

 

1. Physical descriptions of C.A.R.E. Participant:

 

____________________             ____________________             ____________________

                                (height)                                                 (weight)                                                                (hair color)

 

____________________             ____________________             ____________________

                                (eye color)                                              (race)                                                  (gender)

 

 

1. Does he/she have any special interests outside of their residence that he/she is drawn to?  

(For example, trains, water, woods, parks, malls, traffic, etc.): ____________________________

______________________________________________________________________________

1. Has he/she ever run away or been reported as missing? (Check one) ____ Yes _____ No

If yes, please explain: ____________________________________________________________

______________________________________________________________________________

Where was he/she found? _________________________________________________________

1. Is he/she verbal or non-verbal? Explain in detail: ______________________________________

______________________________________________________________________________

1. Does he/she have any fears associated with Police/Fire/EMS personnel or emergency vehicles?

_____ Yes     _____ No                    If yes, please explain: ___________________________________

 

______________________________________________________________________________

1. If he/she becomes confrontational, how could Officers or other emergency personnel calm them without your presence? ___________________________________________________________
2.  
3.  
4. Are you willing to allow the Holliston Police Department to place your address and the information listed here of the C.A.R.E. Participant into our records to insure officers are better prepared to handle any encounters with him/her?                                  (Check one)  _____ Yes     _____ No
5. Please explain in detail any other important information that we may need to know that might assist us in not triggering a violent response from him/her: ______________________________________
6.  
7.  
8. Does he/she have any triggers, i.e., lights, sirens, loud radio noise, etc.        _____ Yes     _____ No

If yes, please explain: ______________________________________________________________

1. Does he/she wear a GPS/LoJack device                                                           _______ Yes     _____ No

 

DO NOT WRITE BELOW THIS LINE

 

 

C.A.R.E. ID#: __________________________Entered By: ________________________