Form Center

2. 
3. Lowell Police Department - Safe Watch Program
5. Please complete the following fields to register an individual for the Safe Watch Program.
9. Submitter's Name*
11. Relation to Individual*
13. Date*
15. Phone Number*
19. Subject's Profile
21. Name*
22. Nickname
24. Street Address*
25. State
26. Zip Code
28. City*
30. Date of Birth*
32. Race/Ethnicity*
    -- Select One --WhiteBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOther (fill in blank)
34. Other
36. Gender*
    -- Select One --MaleFemale
38. Height
39. Weight
40. Eye Color
41. Hair Color
43. Identifying Marks
45. Identifying Items
    (e.g. jewelry, tags, ID card, Medic Alert bracelets)
49. Medical Information
51. Medical Conditions

    1. Autism
    2. Deaf
    3. Blind
    4. Diabetes
    5. Mental Health Issues

    1. Non-Verbal
    2. Other Developmental Disability
    3. Seizures
    4. Brain Injury

    1. Dementia
    2. Alzheimer's
    3. Physical Disability
    4. Other (fill in blank)
53. Other
55. Prescription Medications and Frequency of Dose
57. Treatment or Medical Procedures to Avoid
59. Notes
    (e.g. Sensory or dietary issues; any other relevant medical issues)
61. Is he/she likely to wander?*

    1. Yes

    1. No
65. Habits/ Preferences
67. Favorite attractions or places
69. Distinguishing Behaviors/ Signs of Distress
71. Favorite Objects, Toys, Topics/ Other Likes or Dislikes
73. Effective Approaches/ De-Escalation Techniques
75. Preferred Communication Method
    (e.g. if non-verbal - sign language, pictures, printed words)
79. Emergency Contact Information
81. Primary Contact Name
    (Parents/ Guardians/ Care Providers)
83. Name*
85. Relation to Individual*
87. Address
89. City
90. State
91. Zip Code
93. Phone Number*
94. Email Address
96. Preferred Language of Primary Contact
100. Alternate Contact Name #1
102. Name
104. Relation to Individual
106. Address
108. City
109. State
110. Zip Code
112. Phone Number
113. Email Address
115. Preferred Language of Alternate Contact #1
119. Alternate Contact Name #2
121. Name
123. Relation to Individual
125. Address
127. City
128. State
129. Zip Code
131. Phone Number
132. Email Address
134. Preferred Language of Alternate Contact #2
138. Additional Notes
140. Please Attach a Recent Photo of the Individual
142. For any questions/comments/concerns, please contact Molyka Tieng at MTieng@LowellMA.gov or 978-674-1906.
Leave This Blank:


144. 1. Receive an email copy of this form.
145. Email address

     This field is not part of the form submission.

146. Submit Submit and Print

* indicates a required field