Sabella Fae's Ausome Adventures

Safety Equiptment Request Application

Parent/Guardian Full Name

Recipient Full Name

Recipient Birthday

Month

Day

Year

Recipient Address

Parent/Guardian Phone

Parent/Guardian Email

Preferred Method(s) Of Contact

Phone

Text

Email

Mail

Does Recipient have an Autism diagnosis?

Yes

No

Level of supervision needed?

Low

Moderate

Constant

Is the recipient verbal, minimally verbal, or, non-verbal?

Verbal

Minimally Verbal

Non-Verbal

Does Recipient respond to their name when called aloud or spoken?

Yes

No

Does Recipient have any sensory needs or triggers we should be aware of?

Current biggest safety concern?

Has Recipient ever wandered or eloped?

Wandered

Eloped

Both

How many times in the past 12 months?

Have they ever been found near water, roads, or other dangerous areas?

Yes

No

What current safety measures are being used?

Does the Recipient currently have any safety devices or equipment?

Yes

No

What safety devices and/or equipment do they currently have?

Are any of the devices and/or equipment ineffective or no longer meeting their needs?

Yes

No

What devices and/or safety equipment is ineffective or no longer meets their needs?

In the past 12 months, has Recipient received any prior safety support from another agency or program?

Yes

No

Does Recipient have Handicap tags and/or placard(s) due to their wandering or eloping?

Yes

No

No. Please provide me with more information concerning this in the state of Maryland.

What type of safety equipment or device are you seeking assistance with obtaining for Recipient?

How would it improve Recipients safety?

Is this request urgent?

Yes

No

If request is urgent, please explain why.

Please explain 'OTHER' from above question.

Does Recipient have any of the following currently active?

IFSP

504

IEP

Does financial hardship prevent your family from obtaining the requested item for Recipient?

Yes

No

If yes, please explain.

Before signing and submitting this application I attest to the following:

I have read and agree to the Legal Policies, Terms of Use, and Liability Waiver.

Signature

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Thank you for applying.

Our mission is to help support Autistic individuals and their families by improving safety at home and in the community.

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