Required fields are marked with asterisks (*)

Draper City Police Department Guardian Program

Notice: The Guardian Program is designed to assist law enforcement quickly identify and/or locate missing persons that are endangered due to a diagnosed medical condition that hinders cognitive ability and/or the ability to communicate. This includes, but is not limited to, individuals diagnosed with Alzheimer's and Autism. Individuals who do not suffer from a medical condition that impairs the ability to think and communicate do not qualify for the program. Please contact the Draper City Police Department with any questions regarding this program or its criteria for qualification.

Instructions:

Please fill out the application completely - information requested is required by law to issue an alert.
Please include a recent picture of the applicant - picture should be large and clear without a busy background.
Please provide medical documentation of mental impairment - documentation is required by law in order to issue alert.

Applicant's Information

- Please provide the following information on the person participating in the program.

Last Name

First Name

Middle Name

Nickname or Alias

Date of Birth

License/ID Number

Social Security Number

Phone Number- Primary

Phone Number- Secondary

Address

Height

Weight

Glasses

Yes

Location

Description

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List favorite attractions or locations where the individual may be found in the space provided.

List favorite toys, topics of discussion, likes or dislikes.

Method of preferred communication (verbal, sign language, written words, songs, phrases s/he may respond to).

I.D./Medical Alert jewelry, GPS/Tracking Devices. If GPS is worn, provide manufacturer and transmitter number.

Public safety hazard information. If applicant may become combative if restrained, confronted, etc., provide information below.

Provide any other information about the individual that may be helpful.

Medical Information

- Please provide the following medical information including the name of the condition causing mental impairment.

Primary Care Physician

Phone Number- Primary

After Hours Number

Physician documentation of mental impairment attached?

Yes

Physician Documentation of Mental Impairment Upload

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

All Medical Conditions (including diagnosis of mental impairment)

Prescribed Medications

Drug/Other Allergies

Vehicle Information

- Please provide information for any vehicle the applicant has access to, regardless of current driving status.

Year

Color

Make

Model

License Plate

Distinguishing marks, stickers, body damage:

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Emergency Contact Information

- Please provide the following information for other primary caregivers and emergency contacts.

First Name

Last Name

Phone Number- Primary

Phone Number- Secondary

Address

City

Zip Code

Alternate Contact Number

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Signature

Date

Email- Confirmation of submission will be emailed to this address