C.A.R.E.S. Registration - Seminole Sheriff

Guardian/Representative Information

If you are completing this form on behalf of someone else, please provide your information below.

Your Name

Telephone Number

Email Address

Are you the parent or legal guardian?

Yes No

Available documentation as proof of parentage or guardianship:

A birth certificate as described in s. 382.013 A power of attorney, as defined in 709.2102 A court order establishing parental rights or guardianship Letters of guardianship as described in s. 744.345

Registered Individual Information

Full Name

Nickname(s)

Date of Birth

If 18 years or older, has he/she been declared incapacitated under Chapter 744, F.S.?

Yes No N/A (Under 18)

Recent Photo (Optional)

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Click to upload or drag and drop

PNG, JPG up to 10MB

Email Address

Home Phone

Cell Phone

Residential Address

Race

Sex

Height

Weight

Hair Color

Eye Color

Medical & Behavioral Information

Primary Condition/Disability

Please describe the condition

Additional notes about condition (Optional)

List medications (Optional)

Describe physical condition (Optional)

Walking assistance needed?

Yes No

Describe any violent tendencies (Optional)

Does he/she wander frequently? (Optional)

Is he/she able to wear a bracelet?

Yes No

Favorite toys, topics of interest, or hobbies

Describe daily routine

Key phrases he/she responds to

Fears or triggers

What calms him/her

Best method to approach him/her

Healthcare Providers

Doctor's Name

Doctor's Phone

Hospital Name

Hospital Phone

Dentist Name

Dentist Phone

Are dental records available?

Yes No

Employment & Vehicle Information

Place of Business

Work Phone

Vehicles driven by him/her or that he/she may be a passenger in:

Vehicle Model

Vehicle Year

Vehicle Color

Tag Number

Tag State

Emergency Contact Information

Contact Name

Contact Address

Contact Email

Contact Phone

Additional Phone

Relationship

Additional Emergency Contact