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Alzheimer's / Dementia Alert Application

  1. Alzheimer's / Dememtia Alert Application
    Complete this application, affix a recent photograph, and submit. We will be in contact with you to finish the registration.
  2. The Alzheimer's Patient's Information
  3. Relevent Medical Condtions*
  4. Does He/She Currently Drive (or have access to a vehicle)?
  5. If There Is More Than One Vehicle, Add Below.
  6. Alzheimer's Patient's Habits
  7. 1st Emergency Contact Information
  8. 2nd Emergency Contact Information
  9. Notice
    By submitting this document, the sender agrees to permit the North Kingstown Police Department to use and disseminate any information required during an Alzheimer's Disease, Dementia emergency event.
  10. Leave This Blank:

  11. This field is not part of the form submission.