Home Up

[please print]
Registrant information

Full name ________________________________________

First or nickname __________________________________
(This name will be printed on identification products.)

Street address ____________________________________

City ____________________________________________

County __________________________________________

State ____________   Zip code ______________________

Telephone _______________________________________

Social Security No. _________________________________

Date of birth ______________________________________

Height _________________   Weight __________________

Eye color  ______________   Hair color ________________

Race ____________________________________________

Complexion: Fair___   Medium___   Dark___

Male___   Female ___

Language ________________________________________

Medical conditions _________________________________

Critical medications _________________________________

Circle the characteristics that apply:

Glasses  Contacts  Hearing aid  Wig  Beard 
Mustache  Bald  Cane  Other:_____________

Describe/location:
Mole __________________   Tattoo __________________

Scar __________________   Birthmark ________________

Current photograph provided: Yes___   No___

(Original photo, passport size or larger)

Contact information

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

Name __________________________________________

Address _________________________________________

City ____________________________________________

County __________________________________________

State ____________   Zip code ______________________

Home phone ______________________________________

Work phone ______________________________________

Relation to registrant_______________________________

Additional contacts can be called and receive information if a person is missing or found.
Name __________________________________________

Address _________________________________________

City ____________________________________________

County __________________________________________

State ____________   Zip code ______________________

Home phone ______________________________________

Work phone ______________________________________

Relation to registrant_______________________________


Name __________________________________________

Address _________________________________________

City ____________________________________________

County __________________________________________

State ____________   Zip code ______________________

Home phone ______________________________________

Work phone ______________________________________

Relation to registrant_______________________________


Law enforcement _________________________________
(police or sheriff department nearest registrant’s residence)

Address _________________________________________

City ____________________________________________

County __________________________________________

State ____________   Zip code ______________________

Phone ___________________________________________

Fax _____________________________________________

Registrant Jewerly (please circle type and style)

Type: Bracelet or Necklace
Style:     A     B     C               

jewels1.GIF (8441 bytes)       

Exact Wrist Measurement: __________inches
(Measurement required if ordering bracelet.)

Bracelet measurement instructions: Use a flexible tape measure to determin wrist size, or encircle wrist with string and measure string against a ruler.

jewels2.GIF (9711 bytes)

Caregiver Jewelry Option (please circle type and style)

For an additional $5, order caregiver jewelry. In an emergency, it alerts others that you provide care for a person registered in Safe Return.

Type: Bracelet or Necklace
Style:     A     B     C               

Exact Wrist Measurement: __________inches
(Measurement required if ordering bracelet.)

Release
I, the undersigned, for myself and on behalf of the registrant named above, do hereby authorize the Alzheimer’s Disease and Related Disorders Association, Inc. and the Alzheimer’s Association Safe Return Program (collectively, the “Alzheimer’s Association”) to release the above information in response to emergency calls regarding the registrant and do further agree to indemnify and hold harmless the Alzheimer’s Association, its local chapters and affiliates, Life Crisis Services, Inc., and their respective employees, agents, officers, and directors, from any and all claims (other than willful misconduct) arising out of participation in the Alzheimer’s Association Safe Return Program or the release of the above information.

Furthermore, I hereby represent and warrant to the Alzheimer’s Association that I have full power and authority as the duly authorized representative of the registrant named above, to register and act on his or her behalf.

Contact signature __________________________________

Date ____________________________________________
(Signature/Consent required for registration.)

Registration fee: $40
Caregiver jewelry: $5

Total fee enclosed: _________

Payment method:

___ Phone registration   ___ Mail registration

___ Check $_______

___ Visa   ___ MasterCard

Credit card number _________________________________

Exp. date ________________________________________

Cardholder’s name _________________________________

Cardholder’s signature ______________________________

Mail form, photo, and payment to:


Safe Return
360 Lexington Avenue, 5th Floor

New York, NY 10017