Safety and Assistance Request Form

Name: ____________________________ Nickname: ___________________________
Address: _______________________________________________________________
Hidden Key? _____ If so, where? ___________________________________________
Height: _____ Weight: _____ Hair: _____ Eyes: _____ Glasses? ____ Dentures? _____
Emergency Contacts: 
1.	Name:_________________________________________________________	
Address: _______________________________________________________
Telephone Number (s): ___________________________________________
2.	Name: _________________________________________________________
Address: _______________________________________________________
Telephone Number (s): ___________________________________________
3.	Physician: ________________________ Telephone Number: ____________
Pets and Instructions for Care: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Protective Dog (s)? _____ Describe: ________________________________________________________________________________________________________________________________________________
 
Other Officer Cautions: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Mental Status: ________________________________________________________________________________________________________________________________________________

Special Medical Conditions: ________________________________________________________________________________________________________________________________________________