08-08-22 Handout - Murray Benz8/8/22,10:54 AM Hagler County sheriff launches Autism Awareness Program I Palm Coast I Palm Coast Observer
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SHERIFF
RICK STALY
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PALM COAST MONDAY,APR. 18,2022 3 months ago
Sheriff launches Autism Awareness Program
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The FCSO will be doing its part to customize the way it responds to calls where an autistic person may be present.
by:Don Foley I Public Affairs Manager,Flagler County Sheriff's Office
With April being Autism Awareness Month,Sheriff Rick Staly is launching a new program at the Flagler
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It all begins with a new logo the FCSO has designed to help notify deputies who may be involved in a traffic
stop or a call to a home,business or other location.
https://www.palmcoastobserver.com/article/sheriff-launches-autism-awareness-program 1/7
8/8/22,10:54 AM Hagler County sheriff launches Autism Awareness Program I Palm Coast I Palm Coast Observer
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aware there may be a person with autism and will help us partner with the community in providing special
consideration and sensitivity to your loved ones."
These stickers,along with a brochure sharing all of the details of the Autism Awareness program,will be sent
to those who fill out an informational survey designed and provided by the FCSO Community Engagement
Section.The answers provided in this form will collect specific information for deputies who respond to any
situation where a person with autism maybe on the scene.
This is a free and voluntary database that the FCSO manages to help our Flagler County residents,"Staly
added."It will give residents who deal with the world of autism every day some peace of mind when it comes
to encounters involving the men and women of the FCSO."
All FCSO deputies already receive training on working with autistic individuals.
Residents can find the FCSO Autism Awareness web page at FlaglerSheriff.com.Click"programs"on the top
of the page,then scroll to"autism awareness."
Email CommunityEngagement@FlaglerSheriff.com.
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https://www.palmcoastobserver.com/article/sheriff-launches-autism-awareness-program 2/7
8/8/22,1:52 PM FLAGLER COUNTY SHERIFFS OFFICE/Autism Awareness
Rick Staly, Sheriff
FLAGLER COUNTY SHERIFF'S OFFICE
An honor to serve, a duty to protect."
SIGN UP FOR AUTISM AWARENESS PROGRAM
Name
First Name Last Name
Nicknames
Add Current Photo
Browse Files
Drag and drop files here
form jotform.com/PAOFCSO/flagler-county-sheriffs-office--aut 1/8
8/8/22,1-52 PM FLAGLER COUNTY SHERIFFS OFFICE/Autism Awareness
Date of Birth
MM/DD/YYYY
Date
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or More Races
Other
Sex
Female
Male
Other
Eye Color
Blue
Brown
Green
Hazel
Amber
Gray
Other
Hair Color
form.jotform.com/PAOFCSO/flagler-county-sheriffs-office--aut 2/8
8/8/22,1:52 PM FLAGLER COUNTY SHERIFFS OFFICE/Autism Awareness
Black
Brown
Blonde
Gray
Red
Bald
Other
Height (Ft. and In.)
Weight (Lbs.)
Primary Language Spoken
Diagnosis
Address
Street Address
Street Address Line 2
City State/ Province
form.jotform.com/PAOFCSO/flagler-county-sheriffs-office--aut 3/8
8/8/22,1:52 PM FLAGLER COUNTY SHERIFFS OFFICE/Autism Awareness
Postal/Zip Code
Email
example@example.com
Home Phone
000) 000-0000
Alternate Phone
000) 000-0000
Parent or Caretaker
1. Name
First Name Last Name
Relationship
Work/Home
Cell
form.joiform.com/PAOFCSO/flagler-county-sheriffs-office—aut 4/8
8/8/22,1:52 PM FLAGLER COUNTY SHERIFFS OFFICE/Autism Awareness
2. Name
First Name Last Name
Relationship
Work/Home
Cell
Emergency Contact
First Name Last Name
Relationship
Work / Home
Cell
Questionnaire
formjotform.com/PAOFCSO/flagler-county-sheriffs-office—aut 5/8
8/8/22,1:52 PM FLAGLER COUNTY SHERIFFS OFFICE/Autism Awareness
Is he/she verbal or non-verbal
Verbal
Non-Verbal
If non-verbal, how does he/she communicate?
Type here...
What type of behavior should be expected?
Kicking
Hitting
Biting
Spitting
Self-Hitting
Hand-Flapping
Self-Talk
Body Rocking
Other
What is his/her favorite toy, objects, music, discussion topics, likes and dislikes?
Type here...
What is the best way to approach him/her?
Type here...
Does he/she have any sensitivities/triggers?
Yes
No
Sensitivities/Triggers:
form.jotform.com/PAOFCSO/Hagler-county-sheriffs-office--aut 6/8
8/8/22,1:52 PM FLAGLER COUNTY SHERIFFS OFFICE/Autism Awareness
Light
Siren
Loud Radio Noise
Other
If he/she becomes confrontational, how can Deputies calm him/her down?
Type here...
Any other pertinent information you would like to provide?
Type here...
How many Autism Awareness stickers would you like for your home?
L. One
Two
C Three
Four
How many Autism Awareness stickers would you like for your vehicles?
One
Two
Three
Four
My signature below constitute an affirmation that I am legally responsible for the person
named above for whom I have provided this information
Electronic Signature
form.jotform.com/PAOFCSO/flagler-county-sheriffs-office--aut 7 8
8/8/22,1:52 PM FLAGLER COUNTY SHERIFFS OFFICE/Autism Awareness
Clear
Printed Name
Date
MM/DD/YYYY
Date
If unable to electronically sign, please print form, sign and return to:
communityengagement@flaglersheriff.com or mail to P.O. Box 879, Bunnell, FL 32110
Any question regarding this program or this form, please email
communityengagement@flaglersheriff.com or call 386.586.4845
Distribution: Original to Linked To: FCSO Form #INVS-215 (03/22)
Submit
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