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2. 
4. The WEST U CARES PROGRAM is dedicated to serve the residents of West University Place who may have physical or cognitive impairments (e.g. Alzheimer’s, Dementia, Autism, etc.) and are not able to interact with first responders. If a participant of the West U Cares Program is found wandering or reported missing, first responders will have access to their basic information and a photograph in order to assist them back to their homes or to their loved ones. Registrants will be provided with a free emergency medical information wallet card that he or she can carry.
6. Registering for the West U Cares Program is easy: complete and return the West U Cares Program form with as much information as possible and provide at least one recent photograph of the registrant. The West University Place Police Department can also assist with taking photographs (please call ahead to set an appointment).
8. Photograph rules:

   1. 1. Must be as current as possible
   2. 2. Photographs of registrants under the age of 18 must be updated annually
   3. 3. Must clearly depict and identify the registrant
   4. 4. Image of the registrant by himself or herself preferred

   * Registrants must be residents of West University Place.
10. Registrant Information:
12. First Name*
13. Last Name*
15. Alias (nicknames):
17. Address*
    You do not need to enter a city, state, or zip code.
19. Telephone:*
20. Social Security #:
22. Date of Birth: *
23. Race: *

    1. White
    2. African American
    3. Hispanic
    4. Asian
    5. Indian
    6. Other
24. Sex: *

    1. Male
    2. Female
25. Complexion: *

    1. Fair
    2. Medium
    3. Dark
27. Ethnicity:*
28. Language:*
29. Driver's License Number:
31. Height: *
32. Weight:*
33. Eye Color:*
34. Hair Color*
36. Vehicle Information:
38. Year:
39. Make:
40. Model:
42. Color:
43. License Plate:
45. Medical Conditions or Impairments: *
47. Critical Medications: *
49. Check the characteristics that apply:

    1. Glasses
    2. Contacts
    3. Hearing Aid
    4. Wig
    5. Beard
    6. Mustache
    7. Bald
    8. Walking Cane
51. Describe / Location:
53. Mole:
54. Tattoo:
56. Scar:
57. Birthmark:
59. List favorite attractions/locations where registrant may be found:
61. List favorite toys, idols, topics of discussions, likes/dislikes, triggers/responses:
63. Current Photograph: *

    1. Yes
    2. No
64. Date of Photograph:
65. If available please upload a current photo of the registrant.
67. Emergency Contact Information – Please provide the following information for parent/caretaker/guardian:
69. First Name*
70. Last Name*
72. Address*
74. City*
75. State*
76. Zip*
78. Telephone Number: *
79. Relation: *
80. Driver's License Number:
82. First Name
83. Last Name
85. Address
87. City
88. State
89. Zip
91. Telephone Number:
92. Relation:
93. Driver's License Number:
95. Acknowledgement and Hold-Harmless*
    I, the undersigned, for and in consideration of being extended the opportunity to participate as an Applicant/Caregiver in the “West U Cares” Program (hereinafter, “Program”) facilitated by the West University Place Police Department (hereinafter, “Department”), give the City of West University Place (hereinafter, “City”), the Department, and its representatives permission to disseminate information included in this application, and/or acquired through the investigation of a missing person, as deemed necessary to locate the Applicant in the event he/she is reported missing or endangered in any way that requires law enforcement assistance. I understand that Applicant and/or Caregiver personal information may be disseminated to other public safety agencies, media outlets, volunteer organizations, and the general public in the course of law enforcement providing assistance finding Applicant, and I will not hold the City, the Department, or their representatives liable for any misuse of said personal information. I hereby do assume all risks of injury to Applicant and/or Caregiver arising out of or in any way incident to the above mentioned dissemination of information; that I have read Program information, and with this knowledge I assume whatever risk such Program participation may cause to my person or to a person under my care; and I am free of any condition or limitations which would hamper my ability to participate in said Program. I, the undersigned, for the above-mentioned consideration have covenanted and hereby do covenant never to sue or bring any legal or equitable action in any court whatsoever against the City for any such injury. I further release the City and any officer or employee of the City from any claim whatsoever on account of any services rendered to me as a result of my participation in the aforementioned Program. I hereby assume responsibility for all costs incurred by said participation. I further understand that I may submit a written request that Applicant’s “West U Cares” designation be removed from Department records at any time, and I further understand that this removal will be conducted in compliance with any relevant law relating to records retention or other legal obligations held by the City.
97. Date:*
    Date:
98. Email Address: *
102. Office Use Only:
104. Photo Received? (Y/N)
105. Date of Photo
107. Received By:
108. Date Received:
Leave This Blank:


110. 1. Receive an email copy of this form.
111. Email address

     This field is not part of the form submission.

112. Submit

* indicates a required field