2. 
4. INSTRUCTIONS
   Please complete the necessary fields below. This information is being submitted voluntarily and for the sole purposes of assisting us in locating/identifying your loved one. Once your application has been submitted, a P.A.C.T. officer will contact you to arrange for a current photo to be submitted.
8. Your First Name*
   This should be an adult responsible person and not the subject of the missing critical registration.
9. Your Last Name*
   This should be an adult responsible person and not the subject of the missing critical registration.
11. Address1*
13. Address2
15. City*
16. State*
17. Zip*
19. Your Phone Number*
20. Your Email Address
21. Relationship To Participant*
25. Participant's Information
    Please provide the following information on the person participating in the program.
27. First Name *
    Please put in the legal first name of the person that is being registered.
28. Middle Name
    Please put the legal middle name if applicable.
29. Last Name *
    Please put in the legal last name of the person that is being registered
31. Nickname or Alias
    What name(s) do they use or answer to?
32. Date of Birth
33. TX License or ID Number
35. Social Security Number
    This information is used when entering person into national/state missing persons database.
36. Home Phone Number
37. Cell Phone
39. Cedar Hill Residential Address of Registered Person*
    Please put the residential address of the person being registered. This must be a valid address in Cedar Hill.
41. Gender*
    -- Select One --MaleFemale
42. Age of Missing Critical Person *
43. Height
44. Weight
46. Hair Color
47. Eye Color
48. Facial Hair
49. Glasses?
    -- Select One --YesNo
51. Physical Characteristics
    Please note any scars, marks, tattoos, amputations, prosthetics, deformations, etc. in the space above.
53. Favorite Attractions
    Please list the person's favorite attractions or locations where they may be found in the space above.
55. Toys, Likes & Dislikes
    Please provide a list of the person's favorite toys, topics of discussion, things they like and dislike.
57. Communication
    Please provide the person's preferred communication method (verbal, sign language, written words, songs, phrases they may respond to)
59. I.D./ Medical Alert Jewelry
    Please provide any medical alert jewelry information/ GPS tracking devices, etc. If a GPS is worn, please provide the manufacturer and transmitter number if applicable.
61. Safety Information
    If person may become combative if restrained, confronted etc., please provide information below regarding triggers or methods used to deescalate the situation.
63. Additional Information
    Please provide any additional information about the person which may be helpful for first responders.
67. What is the medical diagnosis of the participant?*
    Please provide us with a basic qualifying diagnosis for this registered person.
69. Primary Care Physician
70. Phone Number
71. After-Hours Number
73. Physician Documentation

    1. Yes
    2. No

    Notice: Documentation is required to issue an alert
75. Medical Conditions
    Please list any other medical conditions.
77. Medications
    Please provide the names of any prescribed medications taken by the person.
78. Drug/ Other Allergies
82. Vehicle Information
    Please provide information for any vehicle the person has access to, regardless of current driving status.
84. Vehicle Year / Color
85. Vehicle Make
86. Vehicle Model
87. License Plate State/ Number
89. Distinguishing marks, damage, stickers, wheels, etc.
91. Vehicle Year/ Color
92. Vehicle Make
93. Vehicle Model
94. License Plate State/ Number
96. Distinguishing marks, damage, stickers, wheels, etc.
100. EMERGENCY CONTACT INFORMATION
     Please provide the following information for other primary caregivers and emergency contacts other than yourself.
102. First Name
103. Last Name
104. Cell Phone
106. Address1
108. City
109. State
110. Zip
111. Alternate Phone Number
113. First Name
114. Last Name
115. Cell Phone
117. Address1
119. City
120. State
121. Zip
122. Alternate Phone Number
124. Acknowledgement & Release
     I give the City of Cedar Hill, Cedar Hill 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 Cedar Hill, the Cedar Hill Police Department or its representatives liable for any misuse of personal information.
126. Signature
     By printing your name, you acknowledge and agree to the above statement.
128. Photo
     Please provide a current photo (within the last week) of the participant. Please do not use a photo of a photo. The photo should be clear, in focus, and not dark in color due to lighting.
130. Thank you for taking the time to provide this valuable information to the Cedar Hill Police Department. Our goal is to quickly and safely get your loved one home. Someone from P.A.C.T. (Police And Community Team) will contact you in the coming days to get further details for full registration.
Leave This Blank:


132. 1. Receive an email copy of this form.
133. Email address

     This field is not part of the form submission.

134. Submit

* indicates a required field