The City of Somerville Silver Alert Program Registration

Name of Potential Wanderer *

Prefix First Name Middle Name Last Name

Birth Date *

Month Day Year

Address *

Primary Phone Number *

- Area Code Phone Number

Secondary Phone Number

- Area Code Phone 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 Code Phone Number

Name of Reporting Party *

First Name Last Name

Relationship to Applicant *

Primary Phone Number *

- Area Code Phone Number

Secondary Phone Number

- Area Code Phone Number

E-mail *

Address of Reporting Party *

Photograph of Potential Wanderer *

Today's Date *

- Month - Day Year

Enter the message as it's shown *

Signature *

For information, please call the Somerville Council on Aging 617-625-1600 x 2300