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Individual's Identifying Information

Full Name

Nicknames (s)

Date of Birth

Phone

Individual's School Information

Does The Individual Go To School In Brantley County

Yes

No

What School Do They Attend?

Private or Other School

Yes

No

Name and Address of the School

Individual's Work Information

Does the individual work in Brantley County?

Yes

No

If yes, what is the name and address?

Individual's Physical Description

Race

Gender

Height

Weight

Hair Color

Eye Colors

Any Distinguishing Features

Individuals Special Concerns or Conditions

List special concerns or conditions

List any medications the individual takes for the concern or condition, as well as any side effects of the medications.

The individual is:

Sensitive to Light

Sensitive to Sound

Sensitive to Smell

Sensitive to Touch

Likely to Become Combative

Likely to Hide

Likely to Flee / Run

Subject to Seizures

Fear of Uniformed Personal (Police / Fire / EMS)

History of Violence

Are There Any Additional Actions Or Triggers Which May Escalate An Interaction With The Individual And:

How Can First Responders Attempt To Better Address The Individal With Specfic Actions Or Techniques If Able:

Responsible Party Submitting Form

Full Name

Relationship to the protected individual:

Parent

Sibling

Spouse

Immediate Family

Friend

Other

Address

Email

Mobile Phone

Home Phone

Emergency Contacts

Contact 1: Full Name

Relationship to the protected individual:

Parent

Sibling

Spouse

Immediate Family

Friend

Other

Mobile Phone

Contact 2: Full Name

Relationship to the protected individual:

Parent

Sibling

Spouse

Immediate Family

Friend

Other

Mobile Phone

Contact 3: Full Name

Relationship to the protected individual:

Parent

Sibling

Spouse

Immediate Family

Friend

Other

Mobile Phone

Brantley County 911 will send an email to the responsible party once this information has been entered into our system.

Thank you for submitting information regarding an individaul who is protected under Logan's Law.

© 2023 Brantley County

POWERED BY: Brantley County

33 Allen Road Nahunta, GA 31553

912-462-5256

© 2023 Brantley County

POWERED BY: Brantley County