Fillable MOUNT AIRY POLICE DEPARTMENT Voluntary Alzheimer/Dementia / Autism (Town of Mount Airy)

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MOUNT AIRY POLICE DEPARTMENT Voluntary Alzheimer/Dementia / Autism (Town of Mount Airy)

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MOUNT AIRY POLICE DEPARTMENT
Voluntary Alzheimer/Dementia / Autism Registry
**Note: All information in RED will be released to the media if a disappearance should occur,
as this information may help ensure a safe return**
(PHOTO)
Date Photo Taken:
Name:
Date of
Birth/Age:
Address:
City/State/Zip:
Emergency Contacts:
Sex:
Race:
Height:
Weight:
Eye color:
Hair color:
Hair Style:
Scars/Marks/Tattoos:
Driver’s License Number:
Driver’s License
State:
Social Security Number:
Vehicles (List all):
Make/Model:
Year:
Color:
License Plate #:
Make/Model:
Year:
Color:
License Plate #:
Medical Concerns (To be released if relevant/necessary):
Page 2
Alzheimer’s Emergency Contact Form
Mount Airy Police Department
Places he/she might go to (example: frequent or familiar places, church, stores, etc.)
________________________________________________________________________
People he/she might go to visit or turn to
________________________________________________________________________
Other names he/she may go by
________________________________________________________________________
Vehicles he/she might have access to
________________________________________________________________________
Has he/she ever had this type of behavior before and if Yes, when
________________________________________________________________________
Any further information that you feel might be pertinent if he/she is lost or missing
Some helpful tips:
10 Signs of Alzheimer’s
1. Memo
ry loss that disrupts daily life.
2. Trouble planning or solving problems.
3. Difficulty completing familiar tasks.
4. Confusion with time or place.
5. Trouble with images and distance.
6. New problems with speaking or writing.
7. Inability to retrace steps.
8. Decreased or poor judgement.
9. Social withdrawal.
10. Changes in mood and personality.
There
are various options that are available to track physical locations such as wristbands,
cell phones, pocket finders and many more to keep your loved one safe.
Thank you for submitting your information. If any information changes or needs updated,
please contact us at 301-829-1424 or you may email police@mountairymd.org.
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MOUNT AIRY POLICE DEPARTMENT Voluntary AlzheimerDementia Autism (Town of Mount Airy)

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Completed 14 July 2020

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