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Guardian Program Application

  1. New Patch
  2. 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.

  3. Application Type
  4. Applicant's Information

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

  5. Glasses
  6. List/describe any scars, marks, tattoos, amputations, prosthetics, deformations in the spaces provided.
  7. Photos of Person Being Registered

  8. Medical Information

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

  9. Notice:  Documentation required to issue alert.

  10. Vehicle Information

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

  11. Primary Vehicle

  12. Secondary Vehicle

  13. Emergency Contact Information

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

  14. Primary Contact Person

  15. Secondary Contact Person

  16. Alternate Contact Person

  17. 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.

  18. **********For Office Use Only**********

  19. Applicant name record created?
  20. Emergency contact name record created?
  21. Alert added to applicant name record?
  22. Emailed IT Support to add address to GIS map?
  23. Premise alert added to applicant address?
  24. Emailed beat officer?
  25. Packet scanned into applicant name record?
  26. Leave This Blank:

  27. This field is not part of the form submission.