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2. 
4. INDIVIDUAL INFORMATION
5. Last Updated (for Office Use):
   Last Updated (for Office Use):

   Last Updated (for Office Use):
7. Already registered? Click here to update:
8. Safe & Sound update
   Submit an updated image and info - ONLY
10. FULL LEGAL NAME*
12. First Name
13. Last Name
15. Nickname or preferred names
17. Address
19. City
20. State
21. Zip Code
23. Gender
    -- Select One --MaleFemale
24. Height:
25. Weight:

    in lbs (preferred)

27. Race:
28. Hair color:
29. Eye color:
31. Verbal?
    -- Select One --VerbalNon-verbal
32. Hearing issues?
    -- Select One --NoneHairing Impaired
34. Preferred Communication Method:
36. Former Military:
37. Fearful of EMS/Fire/Police:
38. Does the individual have access to a vehicle?
40. If Y: Color -
41. Make -
42. Model -
43. Year -
45. License Plate Number:
47. Identifying Marks/Scars/Tattoos:
49. Medical Diagnosis incl any possibility of seizures?:
51. Mental Health Triggers and/or Fears?:
53. Frequented / Favorite Locations?:
55. How should officers approach the individual?
57. Calming Efforts:
59. Interests:
61. CONTACT PERSON (1)

    Emergency Contact

63. Name*
64. Relationship
66. Address
68. Phone Number*
70. CONTACT PERSON (2)
72. Name
73. Relationship
75. Address
77. Phone Number
79. Please attach a recent photo of the individual to this form
81. Please Note

    As a caregiver to this individual, I agree to share all the listed information with Kinston Police Department, Kinston Fire Department, and Lenoir County Emergency Services. I am aware that this information is voluntary and will only be used to ensure the safety of the listed individual if contact is needed by any of the listed agencies. 

83. Printed Name (submitter):
84. Date:
    Date:
86. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
88. Electronic Signature
89. 
Leave This Blank:


91. 1. Receive an email copy of this form.
92. Email address

    This field is not part of the form submission.

93. Submit

* indicates a required field