Project Safe Return Registration Form
The goal of
Project Safe Return
is to aid first responders
in search and rescue operations for at-risk individuals
with cognitive and/or behavioral disorders, who may be
prone to wandering and/or getting lost.
The information requested in this application is critical in
the event the at-risk individual becomes lost.
Additionally, providing this information in advance allows
first responders to identify at-risk individuals who may be
located before being reported missing.
In an effort to keep our records up to date, we request you log in
at least
once every six months
and check the accuracy of the information in the
Participant’s file and replace older photos with new ones.
Please be sure to complete all fields on the application.
By submitting this application, you certify that you are the legal caregiver/
legal guardian of this Participant and are authorized to provide the
information contained in this application.
Person Providing Information
First Name
Last Name
Phone Number
E-mail address
At-Risk Individual (Participant) Personal Information
First Name
Middle Initial
Last Name
Nickname
Date Of Birth
Please provide a valid Address.
Please provide a valid city.
Please provide a valid state.
Please provide a valid zip.
Type of Address:
Nursing Home
Apartment
House
ALF
Race
American Indian
Asian
Black
Unknown
White
Sex
Male
Female
Unknown
Hair Color
Orange
Black
Blonde or Strawberry
Blue
Brown
Green
Gray or Partially Gray
Purple
Pink
Red or Auburn
Sandy
White
Unknown or Bald
Eye Color
Black
Blue
Brown
Green
Gray
Hazel
Maroon
Multicolored
Pink
Unknown
Height:
Feet
Inches
Weight:
Lbs
Known Physical Disabilities:
Known Calming Techniques:
Suggested Ways to Communicate/Interact with Participant:
Has the Participant ever wandered away/gotten lost before?
Yes
No
If yes, please explain:
(Explanation)
Is there a place(s) the Participant likes to go or that we should check first?
Photos
Please upload at least one, and up to three, recent photos of the participant. Photos should be high resolution and taken within last six months. Each file must be under 10MB in size.
A photo is necessary to be able to identify the participant.
Choose Photos
Medical/Miscellaneous Information
Please tell us anything we need to know about the Participant:
Does the Participant Speak English?
Yes
No
If no, what is the Participant’s first language?
(First Language)
Please indicate if the Participant has any of the following:
Scent Kit
Tracker
Bracelet/Necklace
Doctor Information
Doctors Name
Doctors Phone Number
Emergency Contact #1
First Name
Middle Initial
Last Name
Please provide a valid Address.
Please provide a valid city.
Please provide a valid state.
Please provide a valid zip.
Phone Number
Alt Phone Number
E-mail address
Relation to Participant
Emergency Contact #2
First Name
Middle Initial
Last Name
Please provide a valid Address.
Please provide a valid city.
Please provide a valid state.
Please provide a valid zip.
Phone Number
Alt Phone Number
E-mail address
Relation to Participant