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2. Date of Application
   Date of Application
4. Vulnerable Persons Registry Form
6. First Name
7. Middle Name
8. Last Name
10. Nickname(s)
11. Date of Birth
    Date of Birth
12. Age
14. Gender

    1. Male
    2. Female
    3. Decline to Answer
16. Street Number
17. Street Name
18. Street Type
19. Apt #
21. City
22. State
23. Zip
25. Phone Number
27. Employer/School
29. Employer/School
31. Street Number
32. Street Name
33. Street Type
34. Apt #
36. City
37. State
38. Zip
40. Phone Number
42. Physical Characteristics
44. Height
45. Weight
46. Race
47. Complexion
49. Hair Color
50. Hair Style
51. Facial Hair
53. Contacts/Glasses
54. Hearing Device
56. Communicates

    1. Verbal
    2. Non-Verbally
57. Best Method of Communication
59. Birthmarks/Scars/Tattoos/Piercings - Location and Description
61. Dominant Hand

    1. Left
    2. Right
63. Does this person suffer from memory loss or other neuro-divergent condition?
65. Does the individual wear or carry any identification on them?
67. Means of Communication

    The more we know about the way your loved one communicates, the better we can meet their needs. Please be specific in your explanation. 

69. Means of Comfort

    What means are used to comfort your loved one? 

71. Does your loved one have behavior issues?

    If yes, how do you respond? 

73. Please share any other important information that will help identify the risk or assist personnel to care for and maintain the safety of this person.
75. Please list areas where the individual may wander to, including favorite places, parks, shops, friend’s/family’s houses and previous addresses.
77. Does the individual have a set daily routine - Example: walks, visits coffee shops, etc.?
79. What is the best method to approach this individual? Include de-escalation techniques if required:
81. Please list any life-threatening medical concerns and medication required:
83. Please provide any other relevant information:
85. If the person has access to a car please provide the following information:
87. Year
88. Make
89. Model
91. Color of Vehicle
92. License Plate Number
93. State
95. Registered Owner of the Vehicle
97. Emergency Contact for Vulnerable Person
99. Name
100. Relationship
102. Street Number
103. Street Name
104. Street Type
105. Apt #
107. City
108. State
109. Zip
111. Phone
113. Form Completed By
115. Name
116. Relationship
118. Street Number
119. Street Name
120. Street Type
121. Apt #
123. City
124. State
125. Zip
127. Phone
129. Upload Recent Photo of Vulnerable Person
131. Release

     I give my permission to the Little Elm Police Department to retain and distribute this information to first response personnel for the sole purpose of identification and assistance to the person at risk. It will be my responsibility to maintain current contact information. 

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133. 1. Receive an email copy of this form.
134. Email address

     This field is not part of the form submission.

135. Submit

* indicates a required field