Portland Police Department | 109 Middle Street | Portland, Maine 04101 | (207) 874-8479

Impaired Memory Registration

To register a memory/communication impaired individual with the Portland Police Department complete the on-line form below.

If you have any questions concerning this program, please call 207-650-9730 and ask for Senior Lead Officer Poisson. Due to scheduling it might take a few days for her to respond.

* = Required Information

PORTLAND MAINE POLICE DEPARTMENT

If you are reporting a missing person in Portland Maine
DO NOT USE THIS FORM
Call Emergency dispatch at 911, or (207) 874-8574.

PERSON BEING REGISTERED

*Last Name                                 *First and Middle Name
  
*Date of Birth 
 (mm/dd/yyyy)
*Sex
 
 
*Height
 
 
*Weight
 
 
*Street House Number               *Street Name/Apt #
                      
Telephone
Race
Eye Color
 
Hair Color
 

Describe any of the below features

Facial Hair (Beard/Mustache)
Scars
Tattoos
Wig
Glasses
Access to Weapons
Prone to Violence
Sensitive to touch/noise
Verbal or Non Verbal
Med Alert or ID Tags

MEDICAL INFORMATION

Known Physical Disabilities
Known Mental Disabilities
General Physical Condition / Impairment or Diagnosis
Prescribed Medications
Over the Counter Medications
Consequences of Missing Medications
Doctors Name
Doctors Phone Numbers
Doctors Address

CARETAKER INFORMATION

*Caretaker Name

Relationship
*Date of Birth 
 (mm/dd/yyyy)
Email
*Street Address
Telephone (Home)
Telephone (Work)
 
Telephone (Cell)

ADDITIONAL CONTACT INFORMATION

Contact 1

Name

Relationship
Date of Birth

 (mm/dd/yyyy)
Email
Street Address
Telephone (Home)
Telephone (Work)
 
Telephone (Cell)

Contact 2

Name

Relationship
Date of Birth

 (mm/dd/yyyy)
Email
Street Address
Telephone (Home)
Telephone (Work)
 
Telephone (Cell)

You will be contacted by the Portland Police Department for follow up once this registration has been submitted.