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2. 
3. Midlothian Police Department

   The Guardian Program provides immediate access to critical information our first responders need when they encounter those in crisis. Often, those in crisis are not capable of effectively communicating and assisting the responding officer. The person may not be able to identify themselves, may appear lost/disoriented, or might act in a manner that could be misinterpreted by first responders.

5. Application Type

   1. New Application

   1. Renewal

   1. Update

7. Applicant's Information

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

9. Last Name
10. First Name
11. Middle Name
13. Nickname or Alias
14. Date of Birth
    Date of Birth
15. License/ID Number
17. Social Security Number
18. Home Phone Number
19. Cell Phone Number
21. Address (Must be an Ellis County resident)
22. Race
    -- Select One --WhiteBlackHispanicAsianOther
23. Skin Tone
    -- Select One --LightMediumDark
25. Gender
    -- Select One --MaleFemalePrefer not to answer
26. Height
27. Weight
28. Hair
    -- Select One --BlondeBrownBlackRedGreyBaldingBaldOther
30. Eyes
    -- Select One --BrownBlackBlueGreenHazelGrey
31. Facial Hair
    -- Select One --NoneMustacheBeardGoateeMustache & Beard
32. Glasses

    1. Yes
    2. No
36. List/describe any scars, marks, tattoos, amputations, prosthetics, deformations in the spaces provided.
38. Physical Characteristic
    -- Select One --ScarMarkTattooAmputationProstheticDeformation
39. Location
40. Description
42. Physical Characteristic
    -- Select One --ScarMarkTattooAmputationProstheticDeformation
43. Location
44. Description
46. Physical Characteristic
    -- Select One --ScarMarkTattooAmputationProstheticDeformation
47. Location
48. Description
52. List favorite attractions or locations where the individual may be found.
54. List favorite toys, topics of discussion, likes or dislikes.
56. Method of preferred communication (verbal, sign language, written words, songs, phrases s/he may respond to).
58. I.D./Medical Alert jewelry, GPS/Tracking Devices. If GPS is worn, provide manufacturer and transmitter number.
60. Public safety hazard information. If applicant may become combative if restrained, confronted, etc., provide information below.
62. Provide any other information about the individual that may be helpful.

66. Photos of Person Being Registered

68. Front Photo
69. Side Photo

73. Medical Information

    Provide the following medical information including the name of the condition causing mental impairment.

75. Primary Care Physician
76. Phone Number
77. After Hours Number
79. Upload physician documentation of mental impairment.

    Notice:  Documentation required to issue alert.

81. All medical conditions (including diagnosis of mental impairment).
83. Prescribed Medications
85. Drug/other allergies

89. Vehicle Information

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

91. Primary Vehicle

93. Year
94. Color
95. Make
96. Model
98. License Plate
99. Distinguishing marks, stickers, body damage:

101. Secondary Vehicle

103. Year
104. Color
105. Make
106. Model
108. License Plate
109. Distinguishing marks, stickers, body damage:

113. Emergency Contact Information

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

115. Primary Contact Person

117. Last Name
118. First Name
119. Cell Phone Number
121. Alternate Phone Number
122. Address
124. City
125. State
126. Zip Code

128. Secondary Contact Person

130. Last Name
131. First Name
132. Cell Phone Number
134. Alternate Phone Number
135. Address
137. City
138. State
139. Zip Code

141. Alternate Contact Person

143. Last Name
144. First Name
145. Cell Phone Number
147. Alternate Phone Number
148. Address
150. City
151. State
152. Zip Code

156. Authorization

     I give the City of Midlothian, the Midlothian 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 Midlothian, the Midlothian Police Department or its representatives liable for any misuse of personal information.

     Please complete the Affidavit of Consent for yourself or the Affidavit of Consent for 3rd Party for a child or other dependent family member.

158. Upload Affidavit
160. Signature
161. Date
     Date
163. Email Address

167. **********For Office Use Only**********

169. Received By
170. Date Received
171. Time Received
173. Applicant name record created?

     1. Completed
174. Emergency contact name record created?

     1. Completed
176. Alert added to applicant name record?

     1. Completed
177. Emailed IT Support to add address to GIS map?

     1. Completed
179. Premise alert added to applicant address?

     1. Completed
180. Emailed beat officer?

     1. Completed
182. Packet scanned into applicant name record?

     1. Completed
183. Name record entries/scans/etc. verified by?
Leave This Blank:


185. 1. Receive an email copy of this form.
186. Email address

     This field is not part of the form submission.

187. Submit Submit and Print

* indicates a required field