NEW HANOVER COUNTY SHERIFF S OFFICE 3950 Juvenile Center Road Castle Hayne, NC Phone: (910) PROJECT LIFESAVER APPLICATION
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1 NEW HANOVER COUNTY SHERIFF S OFFICE 3950 Juvenile Center Road Castle Hayne, NC : (910) PROJECT LIFESAVER APPLICATION This form is designed to provide information that will be helpful to the New Hanover County Sheriff s Office should the need arise. Providing this information in advance will enable search personnel to respond more effectively. **If a question is not applicable to the client, please enter N/A or t Applicable. ** CLIENT INFORMATION First Middle Last Street Date of Birth Sex City Height Eye Color Race Hair Color Weight Hair Style Facial Hair Zip Build Complexion Does the person wear a wig? Eye Wear Vision without Eye Wear Scars, Marks,Tattoos General Appearance Language(s) Spoken / Understood Does the client wear a hearing aid? Hearing without Aid PRIMARY EMERGENCY CONTACT Alternative File Number OFFICIAL USE ONLY Frequency
2 Facility / School / Day Care of Caregiver / Teacher of Facility Client s Previous Client s Most Recent Occupation of Client s Spouse Living? HEALTH & PSYCHOLOGICAL CONDITION Known Physical Handicaps Does the client use a cane or walker? Known Medical Problems Known Psychological Problems Is the client a danger to self or others? Please explain. Medication(s) Taken Effects of t Taking Medication(s) Other Important Information Client s Physician s
3 PERSONALITY & HABITS Is the client outgoing or quiet? Does the client prefer groups or being alone? Does the client consume alcohol? Does the client abuse medication? Has the client ever been in trouble with law enforcement? Is the client afraid of Dogs ises People The Dark Other Will the client talk to strangers? Actions taken when hurt or scared Is the client religious? Faith Member of a church? of Church Pastor Items Usually Carried by Client - Please be as detailed as possible. Include brands, colors, types of items, etc. Tobacco Products Brand Lighter / Matches Type Candy or Gum Food Items Handbag / Purse / Wallet Money Jewelry / Watch Misc. Items OUTDOOR EXPERIENCE Where was the client born and raised? Is the client familiar with the local area? Areas Client is Familiar with General Athletic Abilities Outdoor Experience Overnight Camping Experience Military Experience Scouting Experience Has the client been lost before? Located where / by who Where & when?
4 Please answer the following questions (1-10) and provide explanations below. 1. Does the client remain oriented to time and person? 2. Does the client recognize familiar persons and faces? 3. Does the client have knowledge of current events? 4. Does the client sometimes clothe themselves improperly? 5. Does the client know his/her name and family members names? 6. Are the client s sleep patterns frequent and consistent? 7. Can the client travel to familiar locations independently? 8. Does the client suffer from frequent personality changes?
5 9. Does the client suffer from delusions (talk to self)? 10. Can the client communicate well with others? EMERGENCY CONTACT INFORMATION of Person Client is Closest to Cell Additional Emergency Contact Cell Additional Emergency Contact Cell ADDITIONAL COMMENTS / INFORMATION of Person Completing Application Date Number of Person Completing Application Print Form Deputy Installing Equipment Date Installed Form OFFICIAL USE ONLY Client Assigned to
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