Guardian Connect - Sign Up

Guardian Connect Sign Up

Name

Date of Birth

Preferred Name

Age

Race

Sex

Height

Hair Color

Weight (lbs)

Eye Color

Glasses?

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Home Address

City

State

Zip Code

Phone Number

Disability

Other Disabilities

Emergency Contact #1 Name

Emergency Contact #1 Phone

Emergency Contact #1 Address

Emergency Contact #1 Relationship to Subject

Emergency Contact #2 Name

Emergency Contact #2 Phone

Emergency Contact #2 Address

Emergency Contact #2 Relationship to Subject

Emergency Contact #3 Name

Emergency Contact #3 Phone

Emergency Contact #3 Address

Emergency Contact #3 Relationship to Subject

Emergency Contact #4 Name

Emergency Contact #4 Phone

Emergency Contact #4 Address

Emergency Contact #4 Relationship to Subject

Are there special interests (outside of their residence) that your loved one is drawn to? (Examples: trains, water, woods, parks, malls, traffic, etc.)

Has your loved one ever run away or been reported as missing? If so, where were they found?

Is your loved one verbal or nonverbal? Please explain.

Does your loved one fear Police or Fire/EMS personnel or emergency vehicles? Please explain.

Does your loved one have any triggers? (Examples: Lights, sirens, loud radio noise, etc.)

If your loved one becomes confrontational, how could Police and Fire/EMS personnel calm them without your presence?

Names of caregivers, parents, grandparents, or other family members involved in your love one's life.

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 enrollment in the Guardian Connect program.

Date of Signature

Email Address