Melrose Alert Registration Form - Melrose Police Department

A collaboration between the Melrose Police Department and the Melrose Council on Aging to protect residents with serious cognitive impairments. For Information, please call (781) 665-4304.

Download and Print the Melrose Alert Form

Name of Potential Wandered*
Date of Birth*
MM slash DD slash YYYY
Primary Phone*
Secondary Phone
Primary Address*
Street Address Address Line 2 City State ZIP Code
Gender
Height
Race
Build
Hair Color
Hair Style
Facial Hair/Style (ie: beard)
Length of Facial Hair
Eye Color
Eye Glasses/Style
Contact Lenses
Medical History*
About You / Emergency Contact
Name of Reporting Party / Primary Contact*
Relationship to the Applicant
Email
Primary Phone*
Secondary Phone
Address*
Street Address Address Line 2 City State ZIP Code

About You / Emergency Contact