Form Center

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
16. 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
17. Please provide a brief description of the disability:
21. Emergency Contact Information
23. Full Name
24. Phone Number
26. Address
27. Relationship
29. Full Name
30. Phone Number
32. Address
33. Relationship
37. Favorite locations where the individual may be found
38. Atypical behaviors or characteristics of the individual that may attract the attention of first responders
40. Individual's favorite object, toy, music, discussion topics
41. Individual's likes and dislikes
43. Method of preferred communication (sign language, pictures, words)
44. Identification Information (Distinguishing marks, tattoos, jewelry, ID cards, Medical Bracelet)
46. Please upload a recent picture of the registered individual
48. 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.
50. Electronic Signature
Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field