Form Center

2. PERSON BEING REGISTERED
4. Last Name*
5. First Name*
6. Middle Initial
8. Email Address
9. Phone Number
10. Cellular Carrier
11. Date of Birth*
    Date of Birth
13. Address*
15. City*
16. State*
17. Zip Code*
19. Sex*
20. Height
21. Eye Color
23. Hair Color
24. Language*
26. Race*

    1. African American
    2. Asian
    3. Hispanic
    4. Indian
    5. White
27. Complexion

    1. Fair
    2. Medium
    3. Dark
29. Regularly Wears

    1. Contacts
    2. Glasses
    3. Hearing Aids
    4. Wig
30. Physical Identifiers

    1. Beard
    2. Birthmark
    3. Moles
    4. Mustache
    5. Scar
    6. Tattoo
32. Typical Clothing Worn
34. List favorite attractions or locations where the individual may be found in the space provided.
36. List favorite toys, topics of discussion, likes or dislikes.
38. Method of preferred communication (verbal, sign language, written words, songs, phrases s/he may respond to).
40. I.D./Medical Alert jewelry, GPS/Tracking Devices. If GPS is worn, provide manufacturer and transmitter number.
42. Public safety hazard information. If applicant may become combative if restrained, confronted, etc., provide information below
46. Medical Information
48. Primary Care Physician
49. Daytime Phone
50. After Hours Number
52. Physician documentation of mental impairment.
    Notice: Documentation required to issue alert.
54. Current Medical Conditions
56. Current Medications
58. Allergies
62. Vehicle Information
    Please provide information for any vehicle the applicant has access to, regardless of current driving status.
64. Year
65. Color
66. Make
67. Model
69. License Plate
70. Distinguishing marks, stickers, body damage
72. Year
73. Color
74. Make
75. Model
77. License Plate
78. Distinguishing marks, stickers, body damage
82. Photos of Person Being Registered
84. Front Photo
85. Side Photo
89. CARE GIVER OR EMERGENCY CONTACT PERSON
91. PRIMARY CONTACT PERSON
93. First Name*
94. Last Name*
96. Address*
98. City*
99. State*
100. Zip Code*
102. Email Address*
103. Phone Number*
105. SECONDARY CONTACT PERSON
107. First Name
108. Last Name
110. Email Address
111. Phone Number
115. ADDITIONAL USEFUL INFORMATION
117. Special Needs Identification Stickers

     These stickers are to indicate that a special needs person are in your home or vehicle.

     1. Home

     1. Vehicle
119. Any additional information you think would be helpful for first responders in finding or interacting with the registered person.
121. To communicate this information to the Rockwall County Sheriff's Office, please click submit below.
Leave This Blank:


123. 1. Receive an email copy of this form.
124. Email address

     This field is not part of the form submission.

125. Submit Submit and Print

* indicates a required field