LostNMissing Inc.

, 26 Noyes Road, Londonderry, NH 03053

SILVER ALERT INFORMATION FORM
Keep on hand in case loved one may wander or go missing.

Individuals Identifying Information

Individual with need:

Name (Last) ___________________

(First) ___________________ M.I ____

Nickname ___________________

Maiden / Other ___________________

Address:
Street Address _____________________________________________________________
Apartment/Unit # ___________________
City

___________________

State __________

Home Phone: ___________________

Zip ____________

Alternate Phone ___________________

Marital Status: M S W
Spouses Name: ____________________________
____

Does spouse live at same residence? Y/N

Address of spouse if different

_____________________________________________________________
Spouses Phone: _______________

Caregiver Info:

Spouses Cell No: _______________

Name (Last)
_______

___________________________ (First) _______________

M.I.

Relationship to individual: _______________

Street Address _____________________________________________________________
Apartment/Unit # _______________
City _______________________ State _________

Zip ________________

Information on Individual:

DOB:_______________
__________

Gender: _________

Right Eye Color: ___________

Height __________

Weight

Left Eye Color: ________________

Cataracts Y/No __________________

Glasses Y/No ______________

Hair Color: ____________________________

Hair Style: __________________________________________________________
(bald, short, cropped, long, ponytail, wig, toupee)
If loved one is already missing, what clothing were they wearing, including shoes?
________________________________
_____________________________________________________________________________
______________________
Race/Nationality (check all that apply. If bi-racial, check both categories)
Is the Individual bi-racial? Y/No ____
____American Indian or Alaska Native
____Black or African American

____Asian

____Caucasian

____Hispanic or Latino

____Native Hawaiian or Other Pacific Islander

____ Middle Eastern

Medical Conditions:

Medications (with dosage)

1.
4.

2.
5.

3.
6.

Emotional Status (well, agitated, hallucinations, anxiety, etc.)_________________________

Does Individual have psychological disorders? Y/No____
Type of Disorders, if any: ____________________________________________
Is Individual at risk of Self Harm? Y/No_________ Under care of Psychiatrist? Y/No _________
Hearing Impairment Y/No _____ Vision impairment Y/No_______ Allergies Y/No?________
List of Allergies __________________________________
Walks unassisted Y/No_________ Uses Cane ________ Other: _________________________
Identifying Marks:

Healthcare Information
Name of Primary Physician:
Specialty of Practice:
Address of Physician:
Phone of Physician:
____________
Name of Specialty Physician:
Specialty of Practice:
Address of Physician:
Phone of Physician:
_____________

Vehicle Information
Does individual drive: Y/No?________
Access to car keys? Y/No_________
YEAR _______ MAKE ______________

MODEL________________
COLOR _________________
Name of State on License Plate _______________
Plate Number (Tag) ______________________

Locations of interest to individual:

(Previous addresses, locations they enjoy and may wander to, etc.)
1.
2.
3.

Are there bodies of water near location of residence (within 2-miles) or from where
individual went missing? (Lake, stream, river, in ground pool, above ground pool, bay,
ocean, etc.)
Y/No? _________ Name of body of water: ______________________________
Location of body of water: ________________________________________
______________________________________________________________

AFFIX PHOTOGRAPHS HERE:

FINGERPRINTS:

RELEASE OF INFORMATION AUTHORIZATION

I, __________________________________caregiver for
____________________________________________
understand that the information contained on this form is strictly confidential and is only
to be used in the event of an emergency. I hereby authorize
_________________________________to share this information with the
___________________________________Police Department and other Emergency
Responders, only in the event of an emergency.
________________________________________
Signature of Caregiver

____________________
Date

LostNMissing Inc., is an all-volunteer national tax-exempt organization under section 501(c)(3) of the Internal Revenue
Code (the "code") and qualifies as a public supported organization under Sections, or Categories: P99 (Human Services Multipurpose and Other N.E.C.); M99 (Other Public Safety, Disaster Preparedness, and Relief N.E.C.); I01
(Alliance/Advocacy Organizations). LostNMissing is organized and incorporated under the laws of the State of New
Hampshire. We never charge a fee for our services.

If youve found this form helpful and wish to make a donation, please visit:

http://lostnmissing.org/donate/

August 3, 2013