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LostNMissing Inc. , 26 Noyes Road, Londonderry, NH 03053

SILVER ALERT INFORMATION FORMKeep on hand in case loved one may wander or go missing.Individuals Identifying Information

Individual with need:

Name (Last) ___________________ (First) ___________________ M.I ____

Nickname ___________________ Maiden / Other ___________________

Address:

Street Address _____________________________________________________________

Apartment/Unit # ___________________

City ___________________ State __________ Zip ____________

Home Phone: ___________________ Alternate Phone ___________________

Marital Status: M S W

Spouses Name: ____________________________ Does spouse live at same residence? Y/N____

Address of spouse if different_____________________________________________________________

Spouses Phone: _______________ Spouses Cell No: _______________

Caregiver Info:

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Name (Last) ___________________________ (First) _______________ M.I._______

Relationship to individual: _______________

Street Address _____________________________________________________________

Apartment/Unit # _______________

City _______________________ State _________ Zip ________________

Information on Individual:

DOB:_______________ Gender: _________ Height __________ Weight__________

Right Eye Color: ___________ Left Eye Color: ________________

Cataracts Y/No __________________ Glasses Y/No ______________

Hair Color: ____________________________

Hair Style: __________________________________________________________(bald, short, cropped, long, ponytail, wig, toupee)

If loved one is already missing, what clothing were they wearing, including shoes?

___________________________________________________________________________________________________________________________________

Race/Nationality (check all that apply. If bi-racial, check both categories)Is the Individual bi-racial? Y/No ____

____American Indian or Alaska Native ____Asian ____Caucasian

____Black or African American ____Hispanic or Latino

____Native Hawaiian or Other Pacific Islander ____ Middle Eastern

Medical Conditions:

Medications (with dosage)

1. 2. 3.

4. 5. 6.

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Emotional Status (well, agitated, hallucinations, anxiety, etc.)_________________________Does Individual have psychological disorders? Y/No____

Type of Disorders, if any: ____________________________________________

Is Individual at risk of Self Harm? Y/No_________ Under care of Psychiatrist? Y/No _________

Hearing Impairment Y/No _____ Vision impairment Y/No_______ Allergies Y/No?________

List of Allergies __________________________________

Walks unassisted Y/No_________ Uses Cane ________ Other: _________________________

Identifying Marks:

Healthcare Information

Name of Primary Physician:

Specialty of Practice:

Address of Physician:

Phone of Physician:____________

Name of Specialty Physician:

Specialty of Practice:

Address of Physician:

Phone of Physician:

_____________

Vehicle Information

Does individual drive: Y/No?________

Access to car keys? Y/No_________

YEAR _______ MAKE ______________

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MODEL________________

COLOR _________________

Name of State on License Plate _______________

Plate Number (Tag) ______________________

Locations of interest to individual:

(Previous addresses, locations they enjoy and may wander to, etc.)

1.

2.3.

Are there bodies of water near location of residence (within 2-miles) or from whereindividual went missing? (Lake, stream, river, in ground pool, above ground pool, bay,

ocean, etc.)Y/No? _________ Name of body of water: ______________________________

Location of body of water: ________________________________________

______________________________________________________________

AFFIX PHOTOGRAPHS HERE:

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FINGERPRINTS:

RELEASE OF INFORMATION AUTHORIZATION

I, __________________________________caregiver for____________________________________________understand that the information contained on this form is strictly confidential and is onlyto be used in the event of an emergency. I hereby authorize_________________________________to share this information with the

___________________________________Police Department and other EmergencyResponders, only in the event of an emergency.

________________________________________ ____________________Signature of Caregiver Date

LostNMissing Inc., is an all-volunteer national tax-exempt organization under section 501(c)(3) of the Internal RevenueCode (the "code") and qualifies as a public supported organization under Sections, or Categories: P99 (Human Services -Multipurpose and Other N.E.C.); M99 (Other Public Safety, Disaster Preparedness, and Relief N.E.C.); I01(Alliance/Advocacy Organizations). LostNMissing is organized and incorporated under the laws of the State of NewHampshire. We never charge a fee for our services.

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If youve found this form helpful and wish to make a donation, please visit:

http://lostnmissing.org/donate/

August 3, 2013

http://lostnmissing.org/donate/http://lostnmissing.org/donate/