Wandering Registration Form Name *FirstLastName of person at riskDate of BirthSexMaleFemaleRaceHair ColorEye ColorHeight *WeightScars/Birthmarks/TattoosHome Address *Home Address 2City/Town *Home PhoneCell PhoneLevel of FunctioningHighLowN/AVerbal / Non-VerbalVerbalNon-VerbalHave they wandered before? *YesNoIf so, where were they located?Closest Water to ResidenceInclude Rivers, Lakes, Ponds, Streams, pools drainage ponds, etc. in the area.Favorite Hiding Place in the homeFavorite Place in the Neighborhood/Community Will they respond to their name being called? *YesNoSensory Issues *YesNoTouchYesNoSoundsYesNoBright LightsYesNoEye ContactGoodFairPoorStimming Behavior (Describe)Processing DelaysYesNoFearsDislikes / Triggers (Describe)Favorite Object or TopicPre-Meltdown SignsMeltdown Behavior (Describe)Calming Strategies that WorkViolence or Prior Contact with PoliceAre there Weapons in the home? *YesNoAre there Alcohol or Drug Issues? *YesNoEmergency Contact Information *FirstLastRelationshipAddressStreet AddressAddress Line 2CityState, Zip / Postal CodeHome PhoneCell PhoneCase Worker NameFirstLastAgencyAgency Phone NumberCase Worker Phone NumberSchool Name (if applicable)GradeSchool AddressStreet AddressAddress Line 2CityState, Zip/ Postal CodeSchool ContactFirstLastSchool Phone NumberPlace of Work (If employed)Work AddressStreet Address Address Line 2CityState, Zip / Postal CodeWork Contact NumberWork Contact PersonFirstLastVehicle Information (if applicable)Please list make / model / year / colorPlate NumberResponsible Person *FirstLastBy filling out the release information you give your permission for any first responder agency (including but not limited to ~ Police / Fire / Rescue / EMS / 9-1-1 Dispatch Center and Search and Rescue personnel) to retain and distribute the information contained in this registration form to other first responder personnel, for the sole purpose of identification and protection of, the person identified above in an emergency or crisis situation.Date SubmittedPhotograph *EMail wanderer@penobscot-county.netMail: Attn: Wanderer Database 97 Hammond St Bangor, ME 04401You must submit a photograph of the person registered for the registration to be completed. You can email a digital photograph to wanderer@penobscot-county.net or you can mail a photograph to: Penobscot Regional Communications Center Attn: Wanderer Database 97 Hammond Street Bangor, ME 04401PhoneSubmit