EMERGENCY CONTACT FORM

This form is for non-emergency communication only. To report an emergency, please dial 911.

The purpose of gathering the information noted below is to enable law enforcement immediate access to the information when a person is located or reported missing who has a cognitive disorder, and/or who is prone to wandering, and/or exhibits life threatening behavior. The submission of this form is encrypted for security; the information contained on this form is kept securely filed and will only be used by law enforcement when necessary. Provide accurate and up-to-date information and at least one (1) forward facing photo of the person. Please update and re-submit the form to this office each time information changes. Your submission is important to us; please include your telephone number and/or email address so we may contact you regarding your submission if needed.

Form submissions via our web site are encrypted for security, however, if you choose to mail the form please mail to:

Leavenworth County Sheriff's Office
601 S 3rd St.
Suite 2007
Leavenworth, KS 66048

Alternately you may click here to print a short form for mailing or call the Leavenworth County Sheriff's Office at (913) 682-5724 to provide the information by telephone.

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PUNCTUATION","name":"PERSONS-CELL-NUMBER","maxlength":10,"className":"d-block","subtype":"text"},{"type":"text","label":"PERSON'S CELLULAR TELEPHONE COMPANY NAME","name":"CELL-COMPANY","className":"d-block","subtype":"text"},{"type":"select","label":"IS THE PERSONS' CELL PHONE GPS TRACKABLE BY AN APP ON AN EMERGENCY CONTACT'S PHONE?","name":"IS-THE-PERSONS-CELL-PHONE-GPS-TRACKABLE-BY-AN-APP-ON-AN-EMERGENCY-CONTACTS-PHONE","className":"d-block","values":[{"label":"NO","value":"NO","selected":true},{"label":"YES","value":"YES"}]},{"type":"text","label":"IF YES, PLEASE PROVIDE THE NAME AND TELEPHONE NUMBER OF THE PERSON THAT CAN TRACK THE CELLULAR DEVICE ","name":"TRACK-CELLULAR-DEVICE-","className":"d-block","subtype":"text"},{"type":"select","label":"DOES THE PERSON WEAR A GPS TRACKABLE DEVICE?","name":"DOES-THE-PERSON-WEAR-A-GPS-TRACKABLE-DEVICE","className":"d-block","values":[{"label":"NO","value":"option-1","selected":true},{"label":"YES","value":"option-2"},{"label":"Option 3","value":"option-3"}]},{"type":"text","label":"IF YES, PLEASE PROVIDE THE NAME AND TELEPHONE NUMBER OF THE PERSON THAT CAN TRACK THE GPS DEVICE ","name":"NAME-OF-PERSON-TRACKING-GPS-","className":"d-block","subtype":"text"},{"type":"date","label":"DATE OF BIRTH","name":"DATE-OF-BIRTH","className":"d-block"},{"type":"select","required":true,"label":"GENDER","name":"GENDER","className":"d-block","values":[{"label":"SELECT","value":"option-1","selected":true},{"label":"FEMALE","value":"option-2"},{"label":"MALE","value":"option-3"},{"label":"PREFER NOT TO SAY","value":""}]},{"type":"select","required":true,"label":"RACE","name":"RACE","className":"d-block","values":[{"label":"SELECT","value":"","selected":true},{"label":"AMERICAN INDIAN OR ALASKA NATIVE","value":""},{"label":"ASIAN OR PACIFIC ISLANDER","value":""},{"label":"BLACK OR AFRICAN AMERICAN","value":""},{"label":"WHITE","value":""}]},{"type":"select","label":"ETHNICITY","description":"ETHNICITY","name":"ETHNICITY","className":"d-block","values":[{"label":"SELECT","value":"option-1","selected":true},{"label":"HISPANIC OR LATINO","value":"option-2"},{"label":"NOT HISPANIC OR LATINO","value":"option-3"},{"label":"PREFER NOT TO SAY","value":""}]},{"type":"number","required":true,"label":"HEIGHT","description":"HEIGHT IN INCHES","name":"HEIGHT-IN-INCHES","min":0,"className":"d-block"},{"type":"number","required":true,"label":"WEIGHT","description":"WEIGHT","name":"WEIGHT","min":0,"className":"d-block"},{"type":"text","required":true,"label":"EYE COLOR","description":"EYE COLOR","name":"EYE-COLOR","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"HAIR COLOR","description":"HAIR COLOR","name":"HAIR-COLOR","className":"d-block","subtype":"text"},{"type":"text","label":"HAIR LENGTH AND STYLE","description":"HAIR LENGTH AND STYLE","name":"HAIR-LENGTH-AND-STYLE","className":"d-block","subtype":"text"},{"type":"select","label":"SKIN TONE","description":"SKIN TONE","name":"SKIN-TONE","className":"d-block","values":[{"label":"SELECT","value":"option-1","selected":true},{"label":"ALBINO","value":"option-2"},{"label":"BLACK","value":"option-3"},{"label":"DARK","value":""},{"label":"DARK BROWN","value":""},{"label":"FAIR","value":""},{"label":"LIGHT","value":""},{"label":"LIGHT BROWN","value":""},{"label":"MEDIUM","value":""},{"label":"MEDIUM BROWN","value":""},{"label":"OLIVE","value":""},{"label":"RUDDY","value":""},{"label":"SALLOW","value":""},{"label":"YELLOW","value":""},{"label":"UNKNOWN","value":""}]},{"type":"select","label":"PHYSICAL BUILD DESCRIPTION","name":"PHYSICAL-BUILD-DESCRIPTION","multiple":true,"className":"d-block","values":[{"label":"SELECT","value":"option-1","selected":true},{"label":"LARGE BUILD","value":"option-2"},{"label":"MEDIUM BUILD","value":"option-3"},{"label":"SMALL BUILD","value":""},{"label":"HEAVYSET","value":""},{"label":"THIN","value":""}]},{"type":"text","label":"PRIMARY LANGUAGE","name":"PRIMARY-LANGUAGE","className":"d-block","subtype":"text"},{"type":"text","label":"PLEASE LIST THE PERSON'S IDENTIFIABLE TATTOOS, SCARS, AND MARKS","description":"PLEASE PROVIDE A DESCRIPTION AND THE LOCATION OF TATTOOS, SCARS, AND MARKS","name":"TATTOOS-SCARS","className":"d-block","subtype":"text"},{"type":"text","label":"PLEASE PROVIDE ALL OTHER PERSONAL FEATURES THAT WILL ASSIST LAW ENFORCEMENT IN IDENIFYING THE PERSON","name":"OTHER-IDENTIFYING-FEATURES","className":"d-block","subtype":"text"},{"type":"text","label":"PERSON'S EMAIL ADDRESS","description":"ADD ANY ADDITIONAL EMAIL ADDRESSES TO THE ADDITIONAL INFORMATION SECTION","name":"PERSONS-EMAIL-ADDRESS","className":"d-block","subtype":"text"},{"type":"header","subtype":"h2","label":"MEDICAL INFORMATION","className":"d-block"},{"type":"checkbox-group","label":"IS THE PERSON DEAF OR HARD OF HEARING?","name":"DEAF---HARD-OF-HEARING","className":"d-block","values":[{"label":"YES","value":"YES"},{"label":"NO","value":"NO"}]},{"type":"checkbox-group","label":"IS THE PERSON BLIND OR VISION IMPAIRED?","name":"BLIND-VISION-IMPAIRED","className":"d-block","values":[{"label":"YES","value":"YES"},{"label":"NO","value":"NO"}]},{"type":"textarea","label":"MEDICAL CONDITION ","description":"LIST ALL CONDITIONS THAT MAY HELP A LAW ENFORCEMENT OFFICER IN CONTACT WITH THE PERSON","name":"MEDICAL-CONDITION-","subtype":"textarea","rows":4,"className":"d-block"},{"type":"textarea","label":"SIGNS OF ESCALATION","description":"PLEASE LIST ALL BEHAVIORS THAT MAY HELP A LAW ENFORCEMENT OFFICE IN CONTACT WITH THE PERSON","name":"SIGNS-OF-ESCALATION","subtype":"textarea","rows":4,"className":"d-block"},{"type":"textarea","label":"COPING SKILLS THE PERSON MAY EXHIBIT","name":"COPING-SKILLS","subtype":"textarea","className":"d-block"},{"type":"textarea","label":"MEDICATIONS","description":"PLEASE LIST INFORMATION CONCERNING MEDICATIONS","name":"MEDICATIONS","subtype":"textarea","rows":2,"className":"d-block"},{"type":"textarea","label":"ALLERGIES & DIETARY RESTRICTIONS","description":"PLEASE LIST ALL ALLERGIES","name":"ALLERGIES--DIETARY-RESTRICTIONS","subtype":"textarea","rows":4,"className":"d-block"},{"type":"textarea","label":"PLEASE PROVIDE PLACES AND ADDRESSES THE PERSON MAY BE DRAWN TO","description":"PLEASE INCLUDE ADDRESSES WHEN POSSIBLE","name":"FREQUENTED-PLACES","subtype":"textarea","className":"d-block"},{"type":"text","label":"VEHICLE COLOR","name":"VEHICLE-COLOR","className":"d-block","subtype":"text"},{"type":"text","label":"VEHICLE MAKE & MODEL","name":"VEHICLE-MAKE--MODEL","className":"d-block","subtype":"text"},{"type":"text","label":"VEICLE LICENSE PLATE & STATE OF ISSUE","name":"VEICLE-LICENSE-PLATE--STATE-OF-ISSUE","className":"d-block","subtype":"text"},{"type":"file","label":"A FRONT FACING PICTURE OF THE PERSON IS REQUIRED - Please select one or more files for upload by clicking the file and pressing the Control key while clicking on additional files before clicking \"Open\".  Files can be PDF, JPG, JPEG format. To upload multiple files, ","name":"FRONT-FACING-PICTURE-OF-PERSON","subtype":"file","multiple":true,"className":"d-block"},{"type":"header","subtype":"h2","label":"EMERGENCY CONTACT INFORMATION","className":"d-block"},{"type":"header","subtype":"h2","label":"# 1 EMERGENCY CONTACT","className":"d-block"},{"type":"text","required":true,"label":"FULL NAME - EMERGENCY CONTACT 1 ","description":"FIRST NAME, MIDDLE NAME, LAST NAME","name":"RP-1-NAME","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"RELATIONSHIP TO PERSON - EMERGENCY CONTACT 1 ","name":"RP-1-RELATIONSHIP-TO-PERSON","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"PRIMARY TELEPHONE NUMBER - EMERGENCY CONTACT 1 ","description":"NUMBERS ONLY","name":"RP-1-TELEPHONE-NUMBER","maxlength":10,"className":"d-block","subtype":"text"},{"type":"text","label":"SECONDARY TELEPHONE NUMBER - EMERGENCY CONTACT 1 ","description":"NUMBERS ONLY","name":"RP-1-SECONDARY-TELEPHONE-NUMBER","maxlength":10,"className":"d-block","subtype":"text"},{"type":"text","label":"EMAIL ADDRESS - EMERGENCY CONTACT 1 ","name":"RP-1-EMAIL-ADDRESS","className":"d-block","subtype":"text"},{"type":"textarea","required":true,"label":"HOME ADDRESS - EMERGENCY CONTACT 1 ","name":"RP-1-HOME-ADDRESS","subtype":"textarea","rows":2,"className":"d-block"},{"type":"header","subtype":"h2","label":"# 2 EMERGENCY CONTACT","className":"d-block"},{"type":"text","label":"FULL NAME - EMERGENCY CONTACT 2 ","description":"FIRST NAME, MIDDLE NAME, LAST NAME","name":"RP-2-NAME","className":"d-block","subtype":"text"},{"type":"text","label":"RELATIONSHIP TO PERSON - EMERGENCY CONTACT 2 ","name":"RP-2-RELATIONSHIP-TO-PERSON","className":"d-block","subtype":"text"},{"type":"text","label":"PRIMARY TELEPHONE NUMBER - EMERGENCY CONTACT 2 ","description":"NUMBERS ONLY","name":"RP-2-TELEPHONE-NUMBER","maxlength":10,"className":"d-block","subtype":"text"},{"type":"text","label":"SECONDARY TELEPHONE NUMBER - EMERGENCY CONTACT 2 ","description":"NUMBERS ONLY","name":"RP-2-SECONDARY-TELEPHONE-NUMBER","maxlength":10,"className":"d-block","subtype":"text"},{"type":"text","label":"EMAIL ADDRESS - EMERGENCY CONTACT 2 ","name":"RP-2-EMAIL-ADDRESS","className":"d-block","subtype":"text"},{"type":"textarea","label":"HOME ADDRESS - EMERGENCY CONTACT 2 ","name":"RP-2-HOME-ADDRESS","subtype":"textarea","rows":2,"className":"d-block"},{"type":"header","subtype":"h2","label":"ADDITIONAL INFORMATION","className":"d-block"},{"type":"textarea","label":"PLEASE INCLUDE ANY ADDITIONAL INFORMATION THAT MAY HELP THE PERSON OR LAW ENFORCEMENT","name":"ADDITIONAL-INFORMATION","subtype":"textarea","className":"d-block"},{"type":"text","label":"NAME OF PERSON SUBMITTING THE FORM","name":"SUBMITTED-BY","className":"d-block","subtype":"text"},{"type":"text","label":"TELEPHONE NUMBER AND/OR EMAIL ADDRESS OF PERSON SUBMITTING THE FORM","name":"SUBMITTER-TELEPHONE-EMAIL","className":"d-block","subtype":"text"}]

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