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2. Purpose of This Program
   To help the Firestone Police Department be better prepared in responses, individuals can utilize this form to self report health concerns or issues within a home. Examples can include medical background information (dementia, hospice care, etc.), mental health concerns, child custody issues and more. This reporting form is a way for individuals to disclose information to the police about their conditions so that when police are faced with challenging situations they have a better understanding of the situation at hand.
   
   By completing this form the signer is authorizing the release of protected health information to law enforcement agencies and other emergency responders.
4. This information will be entered into a Law Enforcement Data System to help responding agencies assist persons with a qualifying illness or condition to obtain medical, mental health and social services when responding to a request for an emergency service. The information will be accessed only to provide necessary information to responding law enforcement officers and other emergency personnel to assist in an emergency situation.
6. Please Check One: *

   1. Enrollment (first time)

   1. Renewal/re-enrollment

   1. Disenrollment/termination
8. Name of Individual to be Entered into the Database:*
10. Date of Birth:*
11. Gender:

    1. Male

    1. Female
13. Drivers License Number:
14. Drivers License State:
18. DESCRIPTION
20. Height:
21. Weight:
22. Hair Color:
23. Eye Color:
25. Scars/Marks/Tattoos:
29. Illness/Condition Information:*
    Provide symptoms, activities or other information that would be helpful for a responding officer to be aware of for the safety of this person and others. Please provide as much information as possible.
31. Diagnosis (if known):
33. Upload option photo if desired:
37. Last Known Address of Person Listed Above:*
39. City
40. State
41. Zip
43. Phone:*
44. Cell:
45. Email:
47. Contact Information:
    Required to have a minimum of two listed. This information will be provided to emergency personnel if the above person is contacted and in need of assistance. Fill out as many as possible.
49. Emergency Contact:
50. Phone:
52. Relationship to person listed above:
54. Case Manager/Clinician:
55. Phone:
57. Probation Officer:
58. Phone:
60. Primary Care Physician:
61. Phone:
65. Name of person submitting this form: *
67. Address:*
68. Phone:*
70. City:*
71. State:*
72. Zip Code:*
74. Email:
75. Relationship:
77. Check Here

    1. I agree my electronic submission of this form constitutes my signature affirming the above information is true and correct.
79. Signature:*
80. Date:*
    Date:

84. For more information, please contact the Firestone Police Department by calling 303-833-0811.

Leave This Blank:


86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit

* indicates a required field