Elderly Citizens Alzheimer’s Dementia Registry - Town of Bristol, Rhode Island

Elder/Adult Alzheimer's Dementia Registration

This form is intended to be completed by the primary caregiver of a person who may wander from his or her home. The information provided will be held in the highest form of confidentiality.

Agency Information

Individual's Information

Vehicle Information

General Questions

Medical Information

Emergency Contact

Submission Notice

If the individual frequents a Senior Center, Adult Day Care Center or lives in a Nursing Home or Assisted Living Facility, Please fill out the following.

Agency Name:

Agency Contact Person:

Agency Phone Number:

Vehicle Information

Please complete this section if the elder/adult has access to a vehicle.

Make & Model:

Year:

Color:

License Plate #:

If there are multiple vehicles, please provide them here:

Does this person tend to wander? If so, do they tend to frequent a particular location?

Do they understand simple directions?

Are they verbally or physically aggressive?

Medical Information

This section is voluntary, you may choose whether or not to share this information.

Primary Care Physician:

Physician's Phone Number:

Medical Conditions or diseases that the indivdual has been diagnosed with:

Medications that the individual takes:

Emergency Contacts

Please indicate the point(s) of contact.

Primary Contact Full Name:*

Primary Contact Address:*

City:*

State:*

Zip Code:*

Primary Contact Phone Number:*

Primary Contact Email Address:

Secondary Contact Full Name:

Secondary Contact Address:

City:

State:

Zip Code:

Secondary Contact Phone Number:

Secondary Contact Email Address:

Submission Notice*

By submitting this document, the sender agrees to permit the Bristol Police Department to use and disseminate any information contained within during an Alzheimer's or related event, in order to locate the individual.