Académique Documents
Professionnel Documents
Culture Documents
Name (Last) Nickname Address: Street Address Apartment/Unit # City Home Phone: Marital Status: M S W Spouses Name: Address of spouse if different Spouses Phone:
M.I
State
Caregiver Info:
Name (Last) Relationship to individual: Street Address Apartment/Unit # City State Zip (First) M.I.
Information on Individual:
Gender:
Weight
Race/Nationality (check all that apply. If bi-racial, check both categories) Is the Individual bi-racial? Y/No ____ ____American Indian or Alaska Native ____Black or African American ____Asian ____Caucasian
Medical Conditions:
2. 5.
3. 6.
Emotional Status (well, agitated, hallucinations, anxiety, etc.)_________________________ Does Individual have psychological disorders? Y/No____ Type of Disorders, if any: ____________________________________________ Is Individual at risk of Self Harm? Y/No_________ Under care of Psychiatrist? Y/No _________ Hearing Impairment Y/No _____ Vision impairment Y/No_______ Allergies Y/No?________ List of Allergies __________________________________ Walks unassisted Y/No_________ Uses Cane ________ Other: _________________________ Identifying Marks:
Healthcare Information
Vehicle Information
Does individual drive: Y/No?________ Access to car keys? Y/No_________ YEAR _______ MAKE ______________ MODEL________________ COLOR _________________ Name of State on License Plate _______________ Plate Number (Tag) ______________________
Locations of interest to individual: (Previous addresses, locations they enjoy and may wander to, etc.) 1. 2. 3.
Are there bodies of water near location of residence (within 2-miles) or from where individual went missing? (Lake, stream, river, in ground pool, above ground pool, bay, ocean, etc.) Y/No? _________ Name of body of water: ______________________________ Location of body of water: ________________________________________ ______________________________________________________________
FINGERPRINTS:
LostNMissing Inc., is an all-volunteer national tax-exempt organization under section 501(c)(3) of the Internal Revenue Code (the "code") and qualifies as a public supported organization under Sections, or Categories: P99 (Human Services Multipurpose and Other N.E.C.); M99 (Other Public Safety, Disaster Preparedness, and Relief N.E.C.); I01 (Alliance/Advocacy Organizations). LostNMissing is organized and incorporated under the laws of the State of New Hampshire. We never charge a fee for our services.
If youve found this form helpful and wish to make a donation, please visit:
http://lostnmissing.org/donate/
August 3, 2013