PERSON WITH AUTISM APPLICATION

I would like to request the posting of a Person with Autism Warning sign(s) for the below individual. I understand that the effectiveness of these types of “warning” signs as a deterrent to pedestrian/vehicle accidents have been difficult to measure. I understand and accept that this sign will not guarantee a person's safety, and that the individual should be accompanied/supervised by a responsible adult. I understand and accept that this sign may bring unwanted attention to the area and/or the diagnosed individual. I understand that the approved sign assembly for DelDOT installations will consist of a Watch Children sign or Pedestrain Warning sign with a plaque underneath that states Person with Autism.

I agree to notify DelDOT Traffic Engineering at 302-659-4600 should the individual no longer require use of this sign or if any contact information changes.

Today's Date

Diagnosed Individual's Full Legal Name

Diagnosed Individual's Date Of Birth

Address

Address line 2

City

Zip

County Value is not selected

Phone Number

Do you currently live In a development

Yes

No

Development Name and/or Homeowners Association Name

Do you currently live in a development maintained by a Homeowners’ Association (HOA) or Civic Association

Yes

No

Legislative Letter

HOA Approval Letter

Primary Email Address

By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding. I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document

Parent/Guardian Full Legal Name:

Signature of Parent/Guardian:

Relationship to Diagnosed Individuals :

Medical Certification Form Attachment

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Person With Autism Form