Form Center

2. Vulnerable Citizens Information
4. Citizen's First Name
5. Citizen's Last Name
6. Nickname (if applicable)
8. Home Address
10. Citizen's Home Phone Number
11. Citizen's Cell Phone Number
12. Citizen's Date of Birth
13. Gender

    1. Male
    2. Female
15. Height
16. Weight
17. Hair Color
18. Eye Color
20. Scars, Tattoos, or Piercings
22. What is the registrants's special need? (i.e. Autism, Alzheimer's, Mental illness etc.)
24. Method of Communication: (Verbal, Non-Verbal, Sign Language, Written, Speech Assistance Device)
26. What language(s) does the registrant speak or understand?
28. Does the registrant utilize any tracking/health equipment? (Project Lifesaver, Life Alert, ect.)
30. Life Threatening Medical Concerns? (Medicine, Allergies, Seizures etc.)
32. Areas that the registrant frequents (playgrounds, pools, stores, friend’s residence etc.)
34. Does the registrant gravitate towards water? If so, can the registrant swim?
36. Any triggers which affect the registrant (i.e., loud noises, bright lights etc.)
38. Any calming methods used for the registrant?
40. Does the registrant have a driver’s license? (If so list license number)
42. Does the registrant own or frequently drive a vehicle? (If so, list make, model, color, and license plate)
44. Does the registrant attend school or are they employed? Name of School/Employer
46. School/Employer Address
48. School/Employer phone number
50. Caregiver's Information
52. Caregiver First Name
53. Cargiver Last Name
55. Caregiver's Relationship with Vulnerable Citizen
57. Caregiver's Home Address
59. Caregiver's Home Phone
60. Caregiver's Cell Phone
62. Additional information you would like to add
64. Citizen's Photograph

    Please upload a photograph of the citizen being registered.  Please post a clear photo of the citizen's face.

66. E- Signature Verification

    1. I agree

    I acknowledge that by clicking the above verification box below that the information being provided is truthful, current, and valid and that I am authorized to submit it on my behalf or as the legal guardian with authority to submit it on behalf of another. I further understand that by enrolling myself or someone else in the Lilburn Police Registry for Vulnerable Citizens, that the personal information entered may be used by emergency personal, including, but not limited to, law enforcement officers, emergency medical services (first aid/paramedics), and fire department personnel in the event of a personal emergency or other emergency situation. It is further understood that completion of this form and participation in the Lilburn Police Registry for Vulnerable Citizens is voluntary and cannot guarantee and is not intended to convey and warrant, either express or implied, as to outcomes, promises, or benefits from the use of this form and participation in this program. By signing below, I also acknowledge that I understand the disclaimer. 

Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

* indicates a required field