PLEASE PRINT THIS FORM AND RETURN IT BY MAIL TO PROJECT LIFESAVER INDIANAPOLIS

APPLICATION FOR SERVICES

 Date: _________________________

 Name of Potential Client:__________________________________________________

 Address:________________________________________________________________

 _______________________________________________________________________

 Phone Number:_________________________ Cell Number:_______________________

 Date of Birth:________________________                   Sex:  Male     Female                     Age:_______________

 Physical condition that leads to wandering:____________________________________

_______________________________________________________________________

_______________________________________________________________________

 Number of times person has wandered / brief description of circumstances… _____________________________________________________________________

________________________________________________________________________________________________________________________________________

Name of Caretaker_________________________________________________________

Relationship ________________________________________________________________

 Phone Number:______________________ Email:________________________________

 Mail form to: Project Lifesaver Indianapolis

                        Wayne Twp Fire Department

                        700 N High School Rd

                        Indianapolis, Indiana 46214

 For Office Use Only:

 PJLS Indianapolis Representative: ____________________________________________

Notes:_____________________________________________________________________

Disposition:_________________________________________________________________________________________________________________________________