Autism Safety Item Request Form

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Serving Hillsborough County Residents

At Experienced Autism Alliance (EAA), we are committed to helping families keep their loved ones safe. Through our Autism Safety Initiative, we provide free safety tools to Hillsborough County residents caring for individuals with autism.

✔ Items provided at no cost while supplies last

✔ Must be a Hillsborough County resident

Email *

Have you requested items before from us?

Yes

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Safety Concerns (Check All That Apply) *

Elopement/Wandering

Bolting From Vehicles

Removing Seatbelt

Opening Doors Unsafely

Water-Seeking Behaviors

Self-Injury

Other:

Required

What safety items are you requesting?

Door Alarm

Secondary Door Lock

Seatbelt Cover (alerts first responders of the individual's condition in the event of a crash)

Water Safety Information

Option 5

Briefly describe why this item would benefit your family

Contact info

Parent/Caregiver Name *

Phone number *

E-mail

Preferred contact method *

Phone

Required

Home Address (City and Zip Code required)

Please provide the full name, age, and diagnosis (optional) of the individual receiving safety support. Please indicate if they are verbal, minimally speaking, or non-verbal.

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