Special Needs Awareness Program Form

Please fill out the form below to enroll a participant in the BAPD SNAP program. Contact Officer Steve Keller at skeller@blueash.com or Officer Beth Roach at broach@blueash.com or (513) 745-8555 if you have any questions.


Participant's Full Name
Home Address of Participant
City or Town
State or Province
Zip or Postal Code
Phone
Cell Phone
Participant's Email Address
Gender
Birthday
Height
Weight
Hair Color
Eye Color
Glasses?
Hearing Aids?
Vehicle Information
Drivers License or ID Number and State of Issue
School or Workplace
School or Workplace Address
Diagnosis of Participant Psychological and Medical
Distinguishing Marks or Traits
Triggers and Dislikes
Calming Techniques
Interests and Favorite Things
Is the participant verbal or nonverbal?
Places Known to Frequent or Previous Address
History
Past Contact with Law Enforcement
Other Helpful Information
Care Giver or Service Provider Name
Nickname used by Participant
Address
City or Town
State or Province
Zip or Postal Code
Phone Number of Care Giver
Cell Number of Care Giver
Work Number of Care Giver
Email of Care Giver
Driver's License Number of Care Giver
State of Issue
Relationship to Participant
Caseworker or Service Facilitator
Agency
Title
Contact Numbers
Who to Contact if Not Available
Contact Information
Other information or comments

Please email a current photo of the participant to skeller@blueash.com or broach@blueash.com.