A POLICE DEPARTMENT REGISTRY TO ASSIST PERSONS AT RISK

 

Instructions:         Complete form, affix photograph and return to:              Lexington Police Department

1575 Massachusetts Avenue

Lexington, MA  02420-3889

Attn: Family Services Officer

 

Last Name

 

 

First Name

MI

For use by the Police Department Only

 

MN#

Personal Description

Affix Recent Photo Here

Date of Birth

 

Race & Sex

Race

Sex

Height

 

Weight

 

Hair Color

 

Eye Color

 

Scars/Marks

Glasses

Facial Hair

 

 

 

Important Address Information

Home

 

 

 

Phone #:

Work

 

 

 

Phone #:

School

 

 

 

Phone #:

Emergency Contacts

AT HOME - Name

 

 

Relationship

Phone

Address

 

 
AT WORK – Name

 

 

 

Relationship

 

 

Phone

 

Address

 

 
AT SCHOOL -- Name

Relationship

Phone

 

 

Address

 

 

OTHER – Name

 

 

Relationship

Phone

Address

SEE  REVERSE  SIDE  OF  THIS  FORM  FOR  IMPORTANT  QUESTIONS

 

 

AT  RISK   INFORMATION

Medical Condition:

 

Physician

 

 

Phone

Address

 

 

Current Medications:

 

 

 

Does person drive?       YES       NO  

If a vehicle is being used, please describe below:

Plate #

 

Make

Model

Year

Color

Does person speak?      YES       NO         If not, how does person communicate?

 

 

Does person wander?   YES        NO        If yes, to where?

 

 

 

Describe medical alert ID, if worn:

 

 

Additional information that will help identify the risk or assist an officer find, communicate with, or care for person.  If necessary, attach a separate sheet.

 

 

 

 

 

 

 

 

 

 

RELEASE

 

I, ________________________________, give my permission to the Lexington Police Department to retain this information, to be kept confidentially on file for the purpose of identification and assistance relative to people at risk and related investigative activities.

 

Print Name: ______________________________________ Signature:               ____________________________________           

 

                                                                                                                Date:       ____________________________________

 

Status update:  _________________________________________________________________________________

 

_____________________________________________________________________________________________

 

_____________________________________________________________________________________________

 

_____________________________________________________________________________________________

 

 

If you have any questions or concerns, please call the Lexington Police Department at (781) 862-1212 and ask to speak with the Family Services Officer or the Desk Officer.