Wanderer Program Registration

This registration form was developed to assist emergency responders in locating and communicating with people that are prone to wander due to Autism, Alzheimer's, Dementia or other mental/medical conditions.  The information provided on this form is secure and private.  The Augusta Police Department would appreciate your help in providing us with information that may help a loved one in a time of need.  You also may pick up a paper copy of this registration form at the police department located at 33 Union Street.  In the event you have any questions about the use of the form please contact Lt. J. Chris Read at the Augusta Police Department at (207)626-2370 ext. 3409 or chris.read@augustamaine.gov.

   
   

Wanderer               
Name:
Address:
City or Town:
State or Province:
Zip or Postal Code:
Phone Home: ex: (207) 626-2370
Phone Cell:  
Height:  
Weight in Pounds:  
Date of Birth: ex: 12/27/1997  
Race:
Sex:  Male      Female
Hair Color:  
Scars/Birthmarks/Tattoos:
Primary Diagnosis:
Level of Functioning:
Verbal:  Yes      No
Mode of Communication if Non-Verbal:
Have they wandered before?  Yes      No
If so, where were they located?
Closest body of Water?
List bodies of water in area of residence.
Favorite hiding place at home?
Favorite place in neighborhood/community?
Will they respond if name is called?  Yes      No
Characteristics.
Sensory Issues?  Yes      No     Type:   Touch      Sound      Light
Eye Contact:  Good      Fair      Poor
Stimming Behavior - Describe
Processing Delays:
Fears:
Dislikes/Triggers:
Favorite Objects or Topics:
Photo Image:
Emergency Contact Person:
Emergency Contact Relationship:
Name of Person Submitting Form:
Contact Number for Submitter: