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2. EMAC ENROLLMENT
4. GENERAL APPLICANT'S INFORMATION
6. First Name
7. M.I.
9. Last Name
10. Nickname
12. Address
14. City
15. State
16. Zip Code
18. Sex

    1. Male
    2. Female
19. Race

    1. Caucasian
    2. African American
    3. Asian
    4. Indian
    5. Hispanic
    6. Unknown
20. Hair Color
21. Eye Color
23. Age
24. D.O.B
26. Height
27. Weight
28. Place of Employment or School
30. Scars / Marks /Tattoos / Piercings
31. Location on Body
33. Home Phone #
34. Cell Phone # & Carrier
36. Work Phone #
37. Email
39. Facebook Username
40. Twitter Username
42. Instagram Username
43. Other Username
45. Vehicle Make
46. Vehicle Model
48. Vehicle License #
49. Vehicle State
50. Vehicle Color
51. Vehicle Year
53. Home Security Camera at Location?

    1. Yes
    2. No
54. Neighbors with Known Cameras?

    1. Yes
    2. No
55. Neighbors with Cameras Name
57. Photo Included in this Packet?

    1. Yes
    2. No
59. How Long Has the Applicant Lived at Current Address?
61. Parent / Guardian / Power of Attorney
63. First Name
64. M.I.
66. Last Name
67. Nickname
69. Address
71. City
72. State
73. Zip Code
75. Home Phone #
76. Cell Phone #
78. Work Phone #
79. Email
81. Sex

    1. Male
    2. Female
82. D.O.B
84. DETAILED APPLICANT INFORMATION
86. First Name
87. M.I.
89. Last Name
90. Nickname
92. Primary Physician's Name
93. Primary Physicians Phone #
95. Medical Conditions

    1. Alcoholism
    2. Allergies
    3. Alzheimer's Disease
    4. Autism (Verbal)
    5. Autism (Non-Verbal)
    6. Bipolar Disorder
    7. Dementia
    8. Diabetes
    9. Down Syndrome
    10. Drug Addiction
    11. Epilepsy / Seizures
    12. Heart Condition
    13. Hearing Impaired / Deaf
    14. Hemophilia
    15. PTSD
    16. Schizophrenia
    17. Suicidal
    18. Other
96. Medical Equipment Used

    1. Cane
    2. Canine Companion
    3. Contact Lens
    4. Dentures
    5. Electric Scooter
    6. Glasses
    7. Hearing Aids
    8. Medical Alert Bracelet
    9. Oxygen
    10. Walker
    11. Wheelchair
    12. Other
98. Specify for Other
99. Specify for Other
101. List Consequences of Not Taking Medications
103. Violent Tendencies
105. Will He / She Respond to Their Name?

     1. Yes
     2. No
107. Known Fears

     1. Being Touched
     2. Dogs
     3. People in Uniform
     4. The Dark
     5. Other
108. Known Attractions

     1. Old Work / School Location
     2. Specific Friends House
     3. Water
     4. Other
110. Specify for Other
111. Specify for Other
113. What are Their Interests, Favorite Things, or Calming Topics?
115. Personal Articles Normally Carried

     1. Candy / Gum
     2. Cell Phone
     3. Clothing / Hat
     4. Identification
     5. Jewelry / Watch
     6. Keys
     7. Pocket Knife / Gun
     8. Purse / Backpack
     9. Wallet / Money
     10. Tobacco / Lighter
     11. Other
116. Describe any Personal Items Normally Carried
118. Has He / She Ever Walked Away Before?

     1. Yes
     2. No
119. If so, Where Were They Found?
121. Does He / She Have Military Training?

     1. Yes
     2. No
122. If so, What Branch?
124. Does He / She Have a CCW Permit?

     1. Yes
     2. No
126. Does He / She Wear a GPS Device?

     1. Apple Watch
     2. Fitbit
     3. Other
128. Specify for Other
130. Certified Service Animal?

     1. Yes
     2. No
131. Is the Pet Microchipped?

     1. Yes
     2. No
132. Pet Type / Color
134. Please Provide any Additional Information That Could Help Us Identify The Person in Question
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136. Submit

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