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Safe Return Program Form

  1. Instructions
    • Please fill out the application completely - information requested is required by law to issue an alert.
    • Please include a recent picture of the participant - picture should be recent, large, and clear.
    • Please provide medical documentation of diagnosis - documentation is required by law in order to issue alert.
  2. Participant Information:
  3. Vehicle(s) Information
  4. Leave blank if does not drive or have access to a vehicle

  5. Physicians Information
  6. Primary Contact
  7. Additional Emergency Contacts
  8. Leave This Blank:

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