Form Center

2. The Guardian Program is designed to assist law enforcement in quickly locating a missing person that are endangered due to a diagnosed medical condition that hinders cognitive ability and/or the ability to communicate. Applicant's Information Please provide the following information on the person participating in the program.
4. First Name*
5. Middle Name*
7. Last Name*
8. Nickname/ Alias
10. Date of Birth*
11. License/ ID Number*
13. Home Phone*
14. Cell Phone*
16. Address (Must be a Glenn Heights resident or attend school within GHPD's jurisdiction)*
18. City
19. State
20. Zip Code
22. Race*
    -- Select One --American Indian/Alaska Native non-Hispanic or LatinoAmerican Indian/Alaska Native Hispanic or LatinoAsian American non-Hispanic or LatinoAsian American Hispanic or LatinoBlack or African American non-Hispanic or LatinoBlack or African American Hispanic or LatinoNative Hawaiian/Other Pacific Islander non-Hispanic or LatinoNative Hawaiian/Other Pacific Islander Hispanic or LatinoWhite or European American non-Hispanic or LatinoWhite or European American Hispanic or Latino
23. Skin Tone*
    -- Select One --Light MediumDark
24. Gender*
    -- Select One --MaleFemaleGender NeutralNon-BinaryTransgenderOther
26. Height*
27. Weight*
28. Hair Color*
29. Eye Color*
31. Facial Hair*
    -- Select One --NoneMustacheGoateMustache and BeardBeard only
32. Glasses*
    -- Select One --YesNo
36. List/Describe any scars, marks, tattoos, amputations, prosthetics, deformations in the spaces provided.
38. Physical Characteristic
    -- Select One --AmputationDeformationMarkProstheticScarTattoo
40. Location
42. Description
44. Upload picture of physical characteristic (optional)

    For example, upload image of tattoo(s) or other appropriate images of physical descriptors.

46. Physical Characteristic
48. Location
50. Description
52. Upload picture of physical characteristic (optional)

    For example, upload image of tattoo(s) or other appropriate images of physical descriptors.

54. List favorite attractions or location where the individual may be found.
58. List favorite toys, topics of discussions, likes or dislikes.
60. Method of preferred communication (verbal, sign language, written words, songs, phrases s/he may respond to).
62. I.D./ Medical Alert jewelry, GPS Tracking Devices. If GPS is worn, provide manufacturer and transmitter number.
64. Public safety hazard information. If applicant may become combative if restrained, confronted, etc., provide information below.
66. Provide any other information about the individual that may be helpful.
70. Medical Information

    Provide the following medical information including the name of the condition causing mental impairment.

72. Primary Care Physician
74. Daytime Phone Number
76. After Hours Number
78. Physician documentation of mental impairment.*

    Notice: Documentation is required to issue alert.

80. All Medical Conditions (including diagnosis of mental impairment)
82. Prescribed Medications
84. Drug/ Other Allergies
88. Vehicle Information

    Please provide information for any vehicle the applicant has access to, regardless of current driving status.

90. Year
91. Color
93. Make
94. Model
96. License Plate
98. Distinguishing marks, stickers, body damage:
102. Photos of Person Being Registered
104. Front Photo
106. Side Photo
110. Emergency Contact Information

     Please provide the following information for other primary caregivers and emergency contacts.

112. Primary Caregiver Contact Information
114. Last Name
115. First Name
117. Address
119. City
120. State
121. Zip Code
123. Cell Phone Number
124. Alternate Phone Number
126. Email Address
128. Secondary Contact Person
130. Last Name
131. First Name
133. Address
135. City
136. State
137. Zip Code
139. Cell Phone Number
140. Alternate Phone Number
142. Email Address
146. Additional Useful Information
148. Any additional information you think would be helpful for first responders in finding or interacting with the registered person.
152. Authorization

     I give the City of Glenn Heights, the Glenn Heights Police Department and its representatives permission to disseminate information included in this application, and/or acquired through the investigation of a missing person, as deemed necessary to locate the applicant in the event s/he is reported missing or endangered in any way that requires law enforcement assistance. I understand that personal information may be disseminated to other public safety agencies, media outlets, volunteer organizations and the general public and do not hold the City of Glenn Heights, the Glenn Heights Police Department or its representatives liable for any misuse of personal information.

154. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
156. Electronic Signature*
158. Date*
     Date
Leave This Blank:


160. 1. Receive an email copy of this form.
161. Email address

     This field is not part of the form submission.

162. Submit Submit and Print

* indicates a required field