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Alzheimer's/ Dementia Registration Form

  1. Registrant Information

  2. First Name

  3. Middle Name

  4. Last Name

  5. Nickname

  6. ie: 415-927-5150

  7. ie: 01/01/1900

  8. ie: 5' 1"

  9. Race

  10. Language Spoken

  11. ie: heart condition, etc.

  12. ie: seizures

  13. Primary Care Doctor

  14. Doctor's Phone Number

  15. Characteristics

    Check all that apply

  16. Please describe

  17. Please describe/ location:

  18. Please describe/ location:

  19. Please describe/ location:

  20. Please describe/ location:

  21. Contact Information

    Primary contact/caregiver is called first if a person is found and may arrange to return registrant.

  22. ie: 415-927-5150

  23. ie: 415-927-5150

  24. ie: 415-927-5150

  25. Additional Contacts

    Persons that can be called and receive information if a person is missing or found.

  26. ie: 415-927-5150

  27. ie: 415-927-5150

  28. Please list make, model, color, and plate information. ie: BMW,325i, black, 1ABC123

  29. ie; local park etc.

  30. Does the registrant know how to use the bus system?

  31. Attach recent photo.

  32. This program is strictly voluntary.

    This program is strictly voluntary. It is designed to assist the Central Marin Police Authority in the swift and safe recovery of your loved ones. A photograph will be taken by the officer who comes to your house. This photograph and data will be entered into the database at the Central Marin Police Authority. In the unlikely event that a loved one wanders away, the police department will already have all the necessary information needed to conduct a thorough and extensive search. This relieves the family of having to attempt to locate the pertinent information during a time of stress, and allows the family to focus on locating the loved one. Thank you for participating in this program. Please be assured that all the data collected will be held in the strictest of confidence and only used by the police. We hope it never has to be utilized, but should be peace of mind for the family and the police knowing the information is already to go if needed.

  33. Leave This Blank:

  34. This field is not part of the form submission.