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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.
   
   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