This card is VOLUNTARY

These cards are meant to be presented to law enforcement, firefighters and emergency medical services personnel to alert them and assist the card holder who has specific needs. The information you will provide will be kept confidential and will be used except for emergency first responders and statistical purposes. If there is a widespread emergency or evacuation that may affect your confidential information may be provided to the first responders.

Alert Cards can be requested on the ASDC website at www.asdchawaii.org or by filling out the form below and mailing it to:

ASDC
P.O. Box 11185
Hilo, Hawaii 96720
(808)339-8726

PLEASE NOTE: IT MAY TAKE SEVERAL WEEKS FOR YOU TO RECEIVE YOUR CARD

Please enable JavaScript in your browser to complete this form.

Name of Card Holder *

First

Last

Guardian *

Caretaker *

Address *

Date of Birth *

Emergency Contact *

Phone *

Email Address *

affect in of

I understand that by checking this box, I may choose not to disclose my disability nor provide any of the information listed in Part 2 or 3 of the application and I will still receive an alert card *

• I agree

Medical or Dietary Issues/Life-sustaining Requirements

Overall Heath

Overall Physical Condition

Known Medical/Dental Issues

Disabilities

Medication

Dosage

Side Effects

Impact if Medication is not taken

Reaction to lights, sirens, aircrafts, canines, people in uniforms, strangers including how the child will respond to each

My agreement with ASDC. I understand that hte information I provide to ASDC will be kept confidential except in needed by emergency first responders or in an event of an emergency or evacuation that may affect me. I also understand that the information I provide may also be used for statistical purposes without identifying me by name *

• I agree

Submit