Caretaker's Assigned Registration for Elderly and Special Needs Program

REGISTRANT INFORMATION

First Name:*

Middle Name:

Last Name:*

Birth Date:*

Height / Weight:*

Hair Color:*

Eye Color:*

Street Address:*

City:*

State:*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code:*

Home Phone Number:

Cell Phone Number:

School Attended:

Employer:

Concerns:*

Dementia (e.g. Alzheimer's) Developmental Disabilities (e.g. Autism Spectrum, Intellectual Impairment)

Other Cognitive Disorders (reasoning impaired,wandering,disoriented or lost)

EMERGENCY CONTACT #1

First Name:*

Last Name:*

Street Address:*

City:*

State:*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code:*

Home Phone Number:

Cell Phone Number:*

Work Phone Number:

Email:

EMERGENCY CONTACT #2

First Name:*

Last Name:*

Street Address:*

City:*

State:*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code:*

Home Phone Number:

Cell Phone Number:*

Work Phone Number:

Additional Information

Please provide additional information that will aid responding emergency personnel to assist in the safety and care of the above-named person.

RELEASE / DISCLAIMER

I give my permission as the Parent/Guardian of the above-named individual to the North Richland Hills Police Department (the Department) to retain and distribute this information to first responding personnel (Fire, EMS, and Police) for the sole purpose of identification and assistance to the above-named person with special needs. The completion of this form shall not create a right to services, nor shall it create a special relationship between the parties. The Department will make a reasonable effort to relay provided information to responding personnel. The Department, however, shall not be held responsible for failure to do so and no guarantee is made, expressed, or implied that said information will be relayed.

By clicking the following statement, I acknowledge that I have read the Release/Disclaimer.*

I do agree with the Release/Disclaimer and I have provided my information below.

First Name:*

Last Name:*

Relationship to Registrant:*

Date of Submission:*

Email:*

Upload current picture.

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

I would like a Silver Alert Bracelet mailed to me.

Yes

No

NOTICE: IT IS THE RESPONSIBILITY OF THE PARENT/GUARDIAN TO NOTIFY THE NORTH RICHLAND HILLS POLICE DEPARTMENT OF ANY CHANGE IN STATUS. ALERTS ARE AUTOMATICALLY REMOVED FROM THE SYSTEM 24 MONTHS FROM THE DATE OF SUBMISSION. ALERTS MUST BE RENEWED EVERY 24 MONTHS.

To be completed by the Police Department:

Registration #

Date to be removed from CAD: