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2. Name (Last, First, Middle)
3. Name Person Answers To
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Email Address
14. Driver's License / ID #
15. State
17. Sex
    -- Select One --FemaleMale
18. Complexion
    -- Select One --Fair Light MediumDark
19. Race
    -- Select One --HispanicAfrican AmericanAmerican IndianAsianWhiteOther
21. Hair Color
22. Eye Color
23. Height
24. Weight
26. Scars / Marks / Tattoos / Birthmarks

    List and describe all that apply

28. Accessories

    List all that apply 
    Examples: Glasses, Hearing Aids, Medical Bracelet 

30. Military Branch
31. ID #
32. Birth City
33. Birth State
35. Education Level
36. School(s)
40. Disability

    1. Autism
    2. Alzheimer's
    3. Dementia
    4. Hearing Impairment
    5. Mental Illness
    6. Mobility Impairment
    7. Speech Impairment
    8. Visual Impairment
    9. Other
41. Please provide a brief description of the disability:
45. Emergency Contact Information
47. Full Name
48. Phone Number
50. Address
51. Relationship
53. Full Name
54. Phone Number
56. Address
57. Relationship
61. Favorite locations where the individual may be found
62. Atypical behaviors or characteristics of the individual that may attract the attention of first responders
64. Individual's favorite object, toy, music, discussion topics
65. Individual's likes and dislikes
67. Method of preferred communication (sign language, pictures, words)
68. Identification Information (Distinguishing marks, tattoos, jewelry, ID cards, Medical Bracelet)
70. Please upload a recent picture of the registered individual
72. Additional Information

    Please provide any additional information about the registered person that may be useful to officers attempting to reunite the person with family. Examples may include doctor or hospital information or other programs/associations the person is registered with.

74. Electronic Signature Agreement

    My signature below constitutes an affirmation under oath that I am legally responsible for the person named above for whom I have provided information and that I consent to have this information shared among law enforcement personnel for Melissa Police Department's Special Needs Program

    1. I agree.
76. Electronic Signature
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

* indicates a required field