Mental/ Neurological Disability Registration Form

Fair Lawn Police Department

Community Policing and Traffic Unit

(201) 794-5365

Section 1. Person Being Registered

Name ( Last, First, MI)

Full Address # Street Apt# Town/City Zip

Alternate Address # Street Apt# Town/City Zip

Home Phone # Date of Birth

Sex Height Weight Eye Color Hair Color Language Spoken

Race ( circle one) ASIAN BLACK WHITE HISPANIC NATIVE AMERICAN OTHER

Complexion ( circle one) FAIR MEDIUM DARK

Regularly wears ( circle) GLASSES CONTACTS WIG HEARING AID

Registrant Has (circle) BEARD MUSTACHE SCARS MOLES TATTOOS BIRTHMARKS

Other Medical Conditions/ Clubs/ Organizations/ Religious Institutions Affiliated with (use extra sheet of paper if necessary)

Section 2 : Photos of Person Being Registered – Place two photos in space below

Mental/ Neurological Disability Registration Form Page 2

Primary Contact Person

Name (First, Last)

Relationship to Registrant

Full Address # Street Apt # Town/City Zip

Home Phone Work Phone Cell Phone/Pager

Please List Two Additional Contacts:

Name ( First, Last)

Relationship to Registrant

Full Address # Street Apt# Town/City Zip

Home Phone Work Phone Cell Phone/Pager

Name ( First, Last)

Relationship to Registrant

Full Address # Street Apt# Town/ City Zip

Home Phone Work Phone Cell Phone/Pager

Please add any other information that you think would be important on an additional sheet.

     I the undersigned, for myself and the registrant named above do hereby authorize the Fair Lawn Police Department to release the aforementioned information in response to any incident regarding the registrant and do further agree to indemnify and hold harmless the Fair Lawn Police Department and any person or agency associated with it.
___________________________    _____________________________ ______________________
     Print name of caregiver/ guardian                Signature of caregiver/ guardian                                       Date