1

Applicant’s Name: (Name of individual for whom this application is being made)

 *

Applicant’s Name: (Name of individual for whom this application is being made)

FAMILY/CAREGIVER INFORMATION

2

Family Member or Caregivers Name:

 *

Family Member or Caregivers Name:

3

Relationship To Applicant:

 *

Relationship To Applicant:

4

Please indicate your authority to enroll this individual in Project Lifesaver®?:

 *

Please indicate your authority to enroll this individual in Project Lifesaver®?:

Spouse

Son or Daughter, in absence of Spouse

Family member having legal, primary caregiver responsibility

Assisted living or nursing home administrator requiring transmitter for client to reside at the facility.

Father or Mother, if client is a minor

Power of Attorney for health care

5

Home Address:

 *

Home Address:

6

Home Phone:

 *

Home Phone:ext.

7

Cell Phone:

 *

Cell Phone:ext.

8

Fax:

Fax:

9

E-mail Address:

 *

E-mail Address:

10

Employer:

 *

Employer:

11

Employer Address:

Employer Address:

12

Work Phone:

 *

Work Phone:ext.

13

Work E-Mail Address:

Work E-Mail Address:

ADDITIONAL EMERGENCY CONTACT INFORMATION

14

Name:

Name:

15

Relationship to Applicant:

Relationship to Applicant:

16

Home Address:

Home Address:

17

Home Phone:

Home Phone:ext.

18

Cell Phone:

Cell Phone:ext.

19

Fax:

Fax:

20

E-mail Address:

E-mail Address:

21

Employer:

Employer:

22

Employer Address:

Employer Address:

23

Work Phone:

Work Phone:ext.

24

Work E-Mail Address:

Work E-Mail Address:

APPLICANT INFORMATION

(Individual who has Alzheimer’s Disease, Autism or related disease)  

25

Full Legal Name: (First name, Middle Name, Last Name)

 *

Full Legal Name: (First name, Middle Name, Last Name)

26

Nickname:

Nickname:

27

What is Applicant’s specific diagnosis?:

 *

What is Applicant’s specific diagnosis?:

28

When was Applicant diagnosed?:

 *

When was Applicant diagnosed?:

29

DOB: (MM/DD/YYYY)

 *

DOB: (MM/DD/YYYY)

30

Current Age: (Years)

 *

Current Age: (Years)

31

Height: (Ft.)

 *

Height: (Ft.)

32

Weight: (Lbs.)

 *

Weight: (Lbs.)

33

Eye Color:

 *

Eye Color:

34

Hair Color:

 *

Hair Color:

35

Describe any other distinguishing physical characteristics:

 *

Describe any other distinguishing physical characteristics:

36

How long as the individual been living at this address?:

 *

How long as the individual been living at this address?:

MEDICAL INFORMATION

37

Is there any prior history of becoming lost or wandering from home?:

 *

Is there any prior history of becoming lost or wandering from home?:

Yes

No

38

If yes, please describe the event(s) in detail with dates:

If yes, please describe the event(s) in detail with dates:

39

Please list the name, address and phone number of the physician who provides treatment to the Applicant:

Please list the name, address and phone number of the physician who provides treatment to the Applicant:

40

Describe any other health related problems:

Describe any other health related problems:

Applicants Name Verification:

41

Applicant’s Name:

 *

Applicant’s Name:

42

Today's Date: (MM/DD/YYYY)

 *

Today's Date: (MM/DD/YYYY)

43

Confirmation On Applicant's Name:

 *

Confirmation On Applicant's Name:

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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