new order form card | Stop and Know

Tag : What would you like to name this order? This is usually the first name of who the item will be for. Make it something you'll remember, it will be needed to locate your order if you need assistance or future QR code updates. (Important: If you've previously ordered other products for this person, please tag this order with the SAME name.)*

Your First Name*

Your Last name*

Your email*

Shipping Street Address*

City*

State*

Zip Code*

Alert Statement for Card (this is the brightly colored area at top of card). *

I am a special needs person

I am autistic

I have epilepsy

I have Down's Syndrome

I am Deaf

I have dementia

I have a mental health disorder

I have schizophrenia

I have a panic disorder

I am non-verbal

I have Parkinson's

Other (type in box below) 3-5 words, single line

Other

Select up to 9 behaviors you want the reader to know. Or add some of your own. Make them short and to the point.*

Loud noise upsets me. Please don't yell at me.

I may have sudden hand movements. I'm not trying to harm you.

Please give me one instruction at a time.

I may not respond to commands.

I may run if I am scared.

I may get agitated if I am scared.

Please tell me before you touch me.

I may not make eye contact. I'm not being rude.

I may not understand you right away. Please be patient with me.

I may give answers unrelated to your question.

I have movement difficulties. It will take me longer to stand etc.

I may have repetitive movements.

I am non-verbal and unable to answer you.

I may not know where I am or where I live.

I am on medication that alters my behavior. Please scan QR code for more info.

Other (fill in boxes below for custom statements)

Other

QR CODE- Emergency Contact (first name only)*

QR CODE- Relationship (mother, father, caregiver, sibling etc...)*

QR CODE- Phone of emergency contact (this should be a number they are reachable at all times. Cell phones are best.)*

QR CODE- Does the person this card is for wish to provide a current medication list?*

Yes

No

Include prescription and over-the-counter drugs and supplements. List medication name, dosage, and frequency, if known. Please ensure accuracy as we will enter this information exactly as it is given to us. Press enter to put each medication on its own line.

QR CODE- Does this person this card is for have any allergies they wish to disclose? *

Yes

No

If yes, enter here

QR CODE- Does the person this card is for wish to share anything else with a first responder or anyone helping them?*

Yes

No

If yes, enter here

Disclosure and Confirmation *

I confirm the information I've provided is accurate to the best of my knowledge. I confirm that I am the person for whom this order is placed or I am authorized to place this order on their behalf. I understand that Stop and Know is not responsible for any errors or inaccuracies provided by me on this order form, including but not limited to, any diagnosis, behavior information, allergies, medications and/or their spellings and dosage. I understand I may request any information embedded in a QR code on the resulting KnowID product be updated free of charge by completing the appropriate update request form. Physical replacement of any KnowID product will incur a cost at the currently published replacement cost which may be found in the FAQ page of this website. I can email hello@stopandknow.org if I need assistance.

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