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Person To Be Registered

First Name*
Last Name*
Middle Initial
Home Address*
City*
State*
Zip Code*
Home Phone Number
Mobile Phone Number*
Mobile Phone Carrier*
(i.e. Verizon, Sprint, T-Mobile, AT&T, etc....)
Date of Birth*
Date of Birth
Gender*
Self-described Gender
Please, describe gender here.
Race*
Select All That Apply
1. American Indian or Alaska Native
2. Asian
3. Black or African American
4. Native Hawaiian or Other Pacific Islander
5. White
6. Other
Ethnicity*
Select One
1. Hispanic or Latino
2. Not-Hispanic or Latino
Complexion*
Build*
Dominate Hand*
Hair Color*
Hair Style*
Eye Color*
Occupation
Employer
Employer Address
Primary Caretaker's Email Address
Attached and Upload a Photo*
Attached and Upload a Quality Digital Photo of Person to be Registered
Approximate Date of Photo*
Approximate Date of Photo
Approximate Age in Photo*
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Registered Person Details

Registered Person Vehicle Information

Type
Make
Model
Year
Color
License State
License Plate
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Primary & Secondary Contacts

Primary Contact
Relation to Person Registered*
Name*
Email Address
Address*
City*
State*
Zip Code*
Home Phone Number
Mobile Phone Number*
Secondary Contact
Relation to Person Registered*
Name*
Email Address
Address*
City*
State*
Zip Code*
Home Phone Number
Mobile Phone Number*
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Acknowledgement

By participating in the Safe Return registration program, I understand and acknowledge that:
The Mt. Juliet Police Department will collect and retain the listed information to respond to calls for service involving the person(s) registered in order to promote effective interaction with him/her, and, if applicable, to return the person home or to another responsible person(s). The Mt. Juliet Police Department will not share or distribute personal information gathered by this form except as required by law and will use it solely for the purposes stated in this document. It is my responsibility to ensure the information submitted is current and accurate, and to notify the Mt. Juliet Police Department in writing of any changes. I may request that the information in this form be withdrawn at any time. Unless I withdraw the information beforehand, the Mt. Juliet Police Department will retain the information for a period of three years, after which it will be purged from the system. Before it is purged, the Mt. Juliet Police Department will send notice to me at the address I provide to determine if I want the information to remain on file for another three years. If the Mt. Juliet Police Department is unable to contact me at the address provided, I understand the information will be purged. By submitting this form, I certify that I have the authority to submit the listed information on behalf of the person to be registered. I understand the terms of this document and consent to the use of the information for the stated purposes.

Leave This Blank:

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

This field is not part of the form submission.
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Acknowledgement

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