Developmental Disabilities Identification Card Request Form

A new state law now makes Identification cards available to New York State residents who have a medically diagnosed developmental disability. These cards are meant to be presented to law enforcement, firefighters and emergency medical services personnel to aid in the communication process. The IDD/ID card are for The Big Island residents ONLY

IDD ID 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, HI 96721

PLEASE NOT THAT IT MAY TAKE SEVERAL WEEKS FOR YOU TO RECEIVE YOUR CARD

PLEASE TYPE OR PRINT CLEARLY

I. Patient Information

Name of Patient

Street Address

APT #

City, State and Zipcode

Date of Birth (MM/DD/YYYY)

Emergency Contact:

Phone

Additional Information:(NOTE: There is a 130-letter maximum limit, including spaces, that will fit on the printed card under "Additional Information." Please count your characters carefully!)

II. Health and General Condition

Medical or dietary issues/life-sustaining requirements

Overall Health

Overall Physical Condition

Known Medical/Dental Issues

Disabilities:

Mental

Physical

Intelluctual

Medication

Dosage

Side Effects

Impact if medication not taken

III. Sensory or Behavioral Triggers

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