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Dearborn Police Department - Special Needs 9-1-1 Registry
Your email
(*)
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Is this a new form or a renewal?
New
Renewal
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Please select the type of disability:
Autism
Downs Syndrome
Alzheimer's
Other
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Specific Diagnosis
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Last Name
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First Name
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Middle Name
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Nickname (if any)
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Male
Female
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Date of Birth (please use MM/DD/YYYY format)
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Race
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Native Hawaiian
Other
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Street address
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City
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State
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Zip
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Home phone (include area code)
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Cell phone (include area code)
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Language Spoken / Non-Verbal
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Method of Communication
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Identification worn?
Yes
No
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Upload photo (if available)
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Date of photo (if attached)
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GPS tracking device worn
Yes
No
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Tracking device website (if yes)
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Height (in Ft-In e.g. 5'7")
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Complexion
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Build (choose one)
Very thin
Thin
Medium
Heavy
Very Heavy
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Hair Color
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Hair Style
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Facial Hair
None
Moustache
Beard
Beard and Moustache
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Eye Color
Brown
Blue
Hazel
Gray
Green
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Marks/Scars/Tattoos (include location)
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Employer/School
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Employer/School Address
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Remarks regarding Employer/School
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Employer/School Phone
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Emergency contact name
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Emergency contact address (if different than person's address)
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Emergency contact phone
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Emergency contact work phone
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Emergency contact mobile phone
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Relationship to person with disability
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Inclination for Wandering or things attracted to:
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Favorite attractions and locations where person might be found:
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Best methods to approach (include approach and de-escalation techniques):
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Life Threatening Medical Concerns:
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What Not To Do (include physical information, direct eye contact, bright lights, loud noises, etc.)
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Other Relevant Information:
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Confirm you are a person
(*)
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