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2. Select One:

   1. New Registry

   1. Update to Existing Registry
3. Date:
   Date:
5. REGISTRANT INFORMATION
   Please complete this section for the subject of this registry. Note: A separate registration form must be submitted for each person to be registered.
7. Last Name:
8. First Name:
9. Middle Name:
11. Date of Birth:
12. Social Security Number:
13. Sex:

    1. Male
    2. Female
15. Height:
16. Weight:
17. Hair Color:
18. Eye Color:
20. Race:
21. Skin Tone:
22. Ethnicity:
24. Please list any scars, marks, tattoos, or piercings and include the location and brief description:
    i.e. tattoo on left wrist of a flower, birth mark on right shoulder, etc.
26. Registrants Address:
27. Apt #
29. City:
30. State:
31. Zip:
33. Registrants Home Phone:
34. Registrants Mobile Phone:
36. Do they live with anyone else? If so, please list names and phone numbers for each individual:
38. Are there any animals in the home?

    1. Yes

    1. No
39. Is there a service animal in your home?

    1. Yes

    1. No
41. If you answered yes to either question above, please list how many and what type:
43. MEDICAL INFORMATION / IMPAIRMENTS
    In this next section please describe to the best of your ability each condition to help us better understand the unique needs of the registrant.
45. Check all that apply:
47. Mobility:

    1. Can walk without assistance
    2. Walk with care
    3. Use walker/crutches

    1. Use wheelchair
    2. Bedridden
    3. Paralysis
48. Hearing:

    1. Hearing Impaired
    2. Deaf
50. Speech:

    1. Speech Impairment
    2. Speech Generating Device

    1. Sign-Language
    2. Written Form
51. Vision:

    1. Vision impaired
    2. Blind
53. Please list any diagnosed medical, mental, or physical disabilities:
55. Do they require any medication for above listed conditions?

    1. Yes
    2. No
57. Please use this box to further explain any condition:
59. Does the registrant tend to wander off?

    1. Yes
    2. No
    3. Sometimes
61. If so, please list any favorite locations or attractions where they may be found:
63. Describe any behaviors or characteristics which may attract attention or endanger this person:
65. Does this registrant wear a medical ID or bracelet, or have some type of pendant or tracking device? If so, please explain:
67. OPTIONAL-Please list any alternate methods of entry into the home that Law Enforcement may use in the event of an evacuation or exigent circumstance:
    i.e. garage code, lock box location and code, hidden key, etc.
69. OPTIONAL: Registrant Photo
    In the event the registrant wanders off or goes missing a recent photograph can be an extremely useful tool to assist Law Enforcement and other first responders in locating them.
71. Caregiver and Emergency Contact Information
73. Caregiver's First and Last Name:
74. Relationship to Registrant:
76. Address:
77. Apartment #:
79. City:
80. State:
81. Zip:
83. Home Phone:
84. Cell Phone:
85. Work Phone:
86. Other:
88. Caregiver's Email:
90. Please list any alternate Emergency Contacts and their phone number(s):
    First and Last Name : XXX-XXX-XXXX
92. IMPORTANT: Please review the following before submitting this form:*

    1. BY CHECKING THIS BOX I ACKNOWLEDGE:

    Responding to this form is strictly voluntary. By completing and submitting this form, I acknowledge that the information provided herein is accurate and was submitted voluntarily. I understand that the information on this form will be added to the Town’s dispatch systems and may be distributed to emergency responders in order to better care for me and my family members. I understand that all information provided may be a public record subject to disclosure to the public. I also understand and acknowledge that the Town’s dispatch center is not a “covered entity” under the Health Insurance Portability and Accountability Act (“HIPPA”) and I have no rights with respect to the possession, use or disclosure of this information by the Town’s dispatch center under HIPPA. I further understand that providing this information does not entitle me or anyone in my household to preferential treatment, including a more timely response by emergency personnel. I recognize that in the event of an emergency I must dial 911. I acknowledge that I am responsible for the accuracy of the information provided and for updating the information when it changes or annually. I further understand that this information may be removed from the database and destroyed after one year until I resubmit the information.
94. Full name of person completing this form:*
95. Relationship to Registrant:*
Leave This Blank:


97. 1. Receive an email copy of this form.
98. Email address

    This field is not part of the form submission.

99. Submit

* indicates a required field