Logan's Law Information Form

WAYNE COUNTY SHERIFF'S OFFICE E911
Special Concerns Response Information
Logan's List (O.C.G.A 38-3-182)

Download a Printable version of this form to fill out and mail or drop off at:
155 N. Wayne Street, Jesup, GA 31546

Downloadable Form

General Information About the Special Concerns Person

Name This field is required

Nickname

Street Address

City

Zipcode

Home Phone 706-555-1212 Invalid Format

Cell Phone 706-555-1212 Invalid Format

Birth Date 09/20/2024 Invalid Format

Race

Gender

Height

Weight

Eye Color

Hair Color

Employer/School Address (only in WAYNE COUNTY 911 jurisdiction)

Special concern or condition Invalid Format

Medications Invalid Format

How does this medication affect actions, responses, senses, the potential for violence, etc.? Invalid Format

Please list any activations or triggers which may escalate an encounter. What actions should be avoided, if possible, by first responders? Invalid Format

Suggestions and techniques that can be taken to resolve a confrontation successfully Invalid Format

This person is:

Sensitive to light Likely to hide Sensitive to touch Likely to fight Subject to seizures Afraid of police/uniformed people Violent Other

Other

Responsible Party Completing This Form

First Name This field is required

Last Name This field is required

Relationship

Address

City

Zipcode

Home Phone 706-555-1212 Invalid Format

Cell Phone 706-555-1212 Invalid Format

Signature

Date 09/20/2024 Invalid Format

Emergency Contact Information

Contact #1 Name

Relationship

Address

City

Zipcode

Home Phone 706-555-1212 Invalid Format

Cell Phone 706-555-1212 Invalid Format

Contact #2 Name

Relationship

Address

City

Zipcode

Home Phone 706-555-1212 Invalid Format

Cell Phone 706-555-1212 Invalid Format

Contact #3 Name

Relationship

Address

City

Zipcode

Home Phone 706-555-1212 Invalid Format

Cell Phone 706-555-1212 Invalid Format