LostNMissing Inc.

, 26 Noyes Road, Londonderry, NH 03053 SILVER ALERT INFORMATION FORM
Keep on hand in case loved one may wander or go missing .

Individual’s Identifying Information
Individual with need:

Name (Last) Nickname Address: Street Address Apartment/Unit # City Home Phone: Marital Status: M S W Spouse’s Name: Address of spouse if different Spouse’s Phone:

(First) Maiden / Other

M.I

State

Zip Alternate Phone

Does spouse live at same residence? Y/N __

Spouse’s Cell No:

Caregiver Info:
Name (Last) Relationship to individual: Street Address Apartment/Unit # City State Zip (First) M.I.

Information on Individual:

DOB: Right Eye Color: Cataracts Y/No Hair Color:

Gender:

Height Left Eye Color: Glasses Y/No

Weight

Hair Style: (bald, short, cropped, long, ponytail, wig, toupee)

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

____Hispanic or Latino ____ Middle Eastern

____Native Hawaiian or Other Pacific Islander

Medical Conditions:

Medications (with dosage) 1. 4.

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

Name of Primary Physician: Specialty of Practice: Address of Physician: Phone of Physician:

Name of Specialty Physician: Specialty of Practice: Address of Physician: Phone of Physician:

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: ________________________________________ ______________________________________________________________

AFFIX PHOTOGRAPHS HERE:

FINGERPRINTS:

RELEASE OF INFORMATION AUTHORIZATION
I, caregiver for understand that the information contained on this form is strictly confidential and is only to be used in the event of an emergency. I hereby authorize to share this information with the Police Department and other Emergency Responders, only in the event of an emergency. ________________________________________ Signature of Caregiver ____________________ Date

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 you’ve found this form helpful and wish to make a donation, please visit:

http://lostnmissing.org/donate/

August 3, 2013

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