At Risk Alzeihmers Wanderer Information Form

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The Fort Fairfield Police Department collects this information in order for us to assist you or your loved one in the event you become lost or missing.

Please contact us if you would like to speak with an officer instead of using the online form. We would be glad to visit and assist you.

Please be as detailed as possible when filling out the form. All information you provide is optional. We would like to have a picture of the person described below. If your registrant wears glasses, we would like to have 2 pictures. One with and one without glasses. We will assist you with a picture or you can email it to bcampbell@fortfairfield.org

Thank you for participating!

Full Name

Address

Phone Number

Date of Birth

Height

Weight

Eye Color

Hair Color

Does the person you are registering wear glasses?

YES

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Please briefly describe his or her diagnosis (Alzheimer’s, M.R. etc):

Please describe any special identification he or she carries:

Please list medications and allergies:

Have seizures?

YES

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Sensitive to touch?

YES

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Please describe his or her eye contact:

Good

Fair

Poor

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Is he or she:

Verbal

Non- Verbal

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Name of primary care physician and or hospital:

Please list a name(s), phone number(s), address(s) of someone we can contact if we find you or your loved one.

Please tell us anything else you would like us to know that would help us:

I give my permission to the Fort Fairfield Police Department to retain and distribute this information to first responders and law enforcement for the sole purpose of identification and assistance of the person at risk. *

YES

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