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Logan's List

This form has been modified since it was saved. Please review all fields before submitting.

General Information About the Person With Special Concerns
First Name*
Last Name*
Nickname
Phone Number
Address*
Birthdate
Birthdate
Race
Gender
Height
Weight
Hair Color
Eye Color
Photo
Employer/School Address (Only if located on Tybee Island)
Special concern or condition*
Medications
How does this medication affect actions, responses, senses, the potential for violence, etc.?
Please list any activations or triggers which may escalate an encounter? What actions should be avoided, if possible, by first responders?*
Suggestions and techniques that can be taken to resolve a confrontation successfully:*
This person is:
1. Sensitive to light
2. Likely to hide
1. Sensitive to touch
2. Likely to fight
1. Subject to seizures
2. Afraid of police/uniformed people
1. Violent
2. Other
Other:
Responsible Party Completing This Form
Name*
Relationship*
Address*
Phone Number
Email*
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Emergency Contact Information
1st Contact
Name*
Relationship*
Primary Contact Phone Number*
Secondary Contact Phone Number
Address
2nd Contact
Name
Relationship
Primary Contact Phone Number
Secondary Contact Phone Number
Address
3rd Contact
Name
Relationship
Primary Contact Phone Number
Secondary Contact Phone Number
Address
BY SUBMITTING THIS FORM, I AM SIGNING THIS FORM ELECTRONICALLY, AND I AGREE THAT MY ELECTRONIC SIGNATURE IS THE EQUIVALENT OF MY MANUAL SIGNATURE ON THIS FORM.

I understand it is my responsibility to resubmit this form annually to maintain my information on the Logan's List. Any changes required prior to the annual update, must be submitted by completing a new form. Please allow three (3) business days for this information to be updated in our system.