Form Center

Elder ID Program - Online Form

2. Elder ID Program

4. The Roeland Park Police Department offers a program for at-risk residents in the city limits of Roeland Park. An identification database is maintained should an at-risk person be missing or is located. This program enables the Police Department to provide helpful information to patrol units and assist in locating a caregiver. <br><br> To register an at-risk resident who resides in the city limits of Roeland Park, please complete this form. You may also print a paper copy of the <a href="/DocumentCenter/View/419/Elder-ID-Program-PDF" target="blank">Elder ID Program Form (PDF)</a> . If printed, please return the form to: <br>Roeland Park Police Department <br>Attention: Records <br>4600 W 51st Street <br>Roeland Park, KS 66205 <br><br> For more information, contact the Roeland Park Police Department at 913-677-3363.

   The Roeland Park Police Department offers a program for at-risk residents in the city limits of Roeland Park. An identification database is maintained should an at-risk person be missing or is located. This program enables the Police Department to provide helpful information to patrol units and assist in locating a caregiver.
   
   To register an at-risk resident who resides in the city limits of Roeland Park, please complete this form. You may also print a paper copy of the Elder ID Program Form (PDF) . If printed, please return the form to:
   Roeland Park Police Department
   Attention: Records
   4600 W 51st Street
   Roeland Park, KS 66205
   
   For more information, contact the Roeland Park Police Department at 913-677-3363.

6. Elder Name*

8. House & Street Address

10. Phone*

12. Elder's Birthdate*
    Elder's Birthdate

13. Race*

14. Height*

15. Weight

17. Sex*

    1. Male

    1. Female

19. Characteristics (Including Scars, Marks & Tattoos)*

    Type "none" if there are no identifying characteristics.

21. Vehicle Description

    Color / Make / Model

22. License Plate Number

24. Places the resident is known to frequent:

26. Additional Information

30. Contact Information

32. Contact Name

33. Contact Phone

35. Contact Name (2)

36. Contact Phone (2)

38. Contact Name (3)

39. Contact Phone (3)

43. Photo Upload*

    A picture is required for this process.

44. Approximate Date of Photo

Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field