Senior Citizen Emergency Program

Name of Indivual*

First Last

Nickname

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Phone

Age*

Sex*

Date of Birth*

Height*

Weight*

Eye Color*

Attach Recent Color Photo*

Max. file size: 50 MB.

What to Know

Communication:*

Verbal

Non-verbal

ASL

Other:

Sensitive To*

Noise

Light

Crowds

Touch

Other:

Medical

hearing Impaired

Vision Impaired

Seizured

Tics

Other:

If you chose "other" for any of the above questions, please explain here:

Identifying Tattos/ Scars/ Deformities

Primary Care Physician*

Phone*

Does the Individual Currently Drive (or have access to a vehicle)?

Make

Model

Year

License Plate

Other Information

If There Is More Than One Vehicle, Add Below.

Alzheimer's Patient's Habits

Does This Person Wander or Do They Have Favorite Attractions or Places Where They May Be Found?*

Do They Understand Simple Directions?*

Are the Verbally or Physically Aggressive?*

Primary Caretaker

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email

Phone

1st Emergency Contact Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email

Phone

2nd Emergency Contact Information

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email

Phone

How Do I Sign Up?

What to Know

Does the Individual Currently Drive (or have access to a vehicle)?

Alzheimer's Patient's Habits

Primary Caretaker

1st Emergency Contact Information

2nd Emergency Contact Information

MAYNARD POLICE DEPARTMENT