BPD Safe Return Program,
Revision 05/2016
Page 1 of 4
Participant Information:
Last Name: First: MI:
Home Address: Apt #:
City: State: Zip:
Home Phone: Work Phone: Cell Phone:
Sex: Race: DOB:
Height: Weight: Hair: Eyes:
Vehicle(s) Information:
Type: Make: Model:
Year: Color:
License State: License Plate:
Vehicle Identification Number:
Type: Make: Model:
Year: Color:
License State: License Plate:
Vehicle Identification Number:
Physicians Information:
Physicians name:
Documented diagnosis : (attach physician’s letter)
Co-existing medical condition(s):
Prescribed medication(s):
Is an ID bracelet/Medical Alert jewelry/GPS worn by participant?:
Instructions:
Please fill out the application completely - information requested is required by law to issue an alert
Please include a recent picture of the participant - picture should be recent, large and clear
Please provide medical documentation of diagnosis - documentation is required by law in order to issue alert
BPD Safe Return Program,
Revision 05/2016
Page 2 of 4
Primary Contact:
Relationship to participant:
Last Name: First: MI:
Sex: Race: DOB:
Home Address: Apt #:
City: State: Zip:
Home Phone: Work Phone: Cell Phone:
Does participant live with you?
If no, who provides care for the participant?
Care provider’s contact phone number(s):
Additional Emergency Contacts:
Name: Relationship to participant:
Home Phone: Work Phone: Cell Phone:
Name: Relationship to participant:
Home Phone: Work Phone: Cell Phone:
Name: Relationship to participant:
Home Phone: Work Phone: Cell Phone:
BPD Safe Return Program,
Revision 05/2016
Page 3 of 4
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Participant Details
Diagnosis/Disability (check all that apply):
ADHD
Autism/Asperger’s Syndrome
Brain Injury
Deaf/Low Hearing
Down Syndrome
Intellectual Disability
Other Mental Disability
Other Developmental Disability
Communication Method (check all that apply):
Alzheimer’s Disease
Blind/Low Vision
Cerebral Palsy
Diabetic
Epilepsy/Seizures
Mental Illness
Physical Disability
Dementia
Verbal Non-Verbal
Speech Difficulty Assisted Communication Device
Picture Exchange Communication System Sign Language (ASL)
Hearing Difficulty Non-Communicative
Language other than English:
Special Considerations (check all that apply):
Combative Combative if Restrained
Fear of Officers or Uniformed Individuals Fear of Dogs
Hugs Light Sensitive
Noise Sensitive Paranoid
Repeats Phrases Run Tendency
Self-Stimulatory Behavior Sensitive to Stimulation
Touch Sensitive Unresponsive to Strangers
Water Fixation (Attraction) Disrobes or Prefers Nudity
BPD Safe Return Program,
Revision 05/2016
Page 4 of 4
Additional Details
1. If the registered person has a tendency to wander, please describe places he/she have been found recently
or may choose to go:
2. Medical or psychological concerns relevant to police officers attempting to assist the registered person to
remain safe and return home:
3. Suggestions for ways a police officer can approach and help the participant:
4. Regular behaviors, past locations and known routines that are significant to the participant:
5. Additional information you feel would be important for the police to know:
BPD Safe Return Program,
Revision 05/2016
Page 5 of 4
Photograph
Include or attach a single photograph of the participant. The image should be of good contrast and show the
subject in a well-lit condition.
Date of Photograph: Age in Photograph:
ACKNOWLEDGMENT
By participating in Bedford’s Safe Return registration program, I understand and acknowledge that:
The Bedford Police Department will collect and retain the listed information to respond to calls for
service involving the person registered in order to promote effective interaction with him/her, and, if
applicable, to return the person home or to another responsible person(s).
The Bedford Police Department will not share or distribute personal information gathered by this form
except as required by law and will use it solely for the purposes stated in this document.
It is my responsibility to ensure the information submitted is current and accurate, and to notify the
Bedford Police Department in writing of any changes.
I may request that the information in this form be withdrawn at any time.
The Bedford Police Department will provide an annual notice for information to remain on file in the
registry. If the Bedford Police Department is unable to contact me at the address provided, I understand
the information will be purged.
By signing below, I certify that I have the authority to submit the listed information on behalf of
the person to be registered. I understand the terms of this document and consent to the use of the
information for the stated purposes.
Signature: Date:
Print Name:
******************************FOR OFFICE USE ONLY - DO NOT WRITE BELOW THIS LINE******************************
Received by: Date Received:
Time Received:
click to sign
signature
click to edit
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