Project Lifesaver Client & Caregiver Application

This application is designed for custodial caregivers to apply for participation in the Fairfax County Sheriff’s Office Project Lifesaver program. By completing and submitting this form you will be considered for participation in Project Lifesaver. You will be sent additional materials to complete and assigned a place on the waiting list. The following information applies to our policies concerning the waiting list.

1. Clients will be taken off the waiting list and put into Project Lifesaver on a first come – first served basis.
2. If a potential client is referred to us that has a documented (police report) case of wandering, they will be given priority.
3. Additional potential clients that have documented wandering cases will also be added on a first come – first served basis and have priority over potential clients with no documented cases of wandering.
4. We will place all potential clients on the list who have been referred from other agencies or who contact Project Lifesaver directly.

* indicates required information

Client Information 

* Client Name:   

* Address:       

* City/State:    

* Zip Code:      

* Date of Birth: 

* Sex:   Male    Female

* What's the client's disorder?

* Has the client ever been lost? Yes No

  If yes, where and when?

  How was he/she found? By whom?

  Was a law enforcement authority notified?  Yes No

  If yes, name of agency notified:

Caregiver Information

* Name:     

* E-mail:    

* Address:  

* City/State:

* Zip Code:  

* Home Phone:

  Work Phone:  

  Cell/Pager:

* Relationship to Client: