The City of At Risk Persons Alert Program Registration

Name of Person at Risk*

PrefixFirstMiddle Last Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone Number*

Area CodePhone Number
Cell Number

Area CodePhone Number
Gender*
Height*
Build
Race*
Hair Color
Hair Style
Facial Hair (beard, etc)
Length of Facial Hair
Eye Color
Eye Glasses
Eye Glass Style
Contact Lenses
Preferred Hospital*
Physician Name
Physician Phone Number

Area CodePhone Number
Additional Info
Reporting Party
Name of Reporting Party*

First NameLast Name
Relationship to Applicant*
Primary Phone Number*

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
example@email.com
Address of Reporting Party*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Photograph of Potential Wanderer*
Today's Date

MonthDayYear
Enter the message as it's shown*
Signature*
For information, please call the Somerville Council on Aging 617-625-6600 x 2310
Should be Empty:

Reporting Party