Apply for the Project Lifesaver Program

Complete the form below to have the client considered for the Project Lifesaver Program. You will receive a response within 48 hours of submission.

Note: Specific criteria must be met to qualify. Participants in the program must be monitored 24 hours a day, seven days a week, and not live alone. This tracking program is the absolute last step in safety.

Fields marked with an asterisk are required.

Potential Client Information

Name

First Name

Middle Name

Last Name

Address

Street Address

City

State

ZIP Code

Phone Number

Date of Birth

Sex

Female

Male

Diagnosed Condition

Questions	Yes	No
Have a 24-hour caregiver	Yes	No
Drive	Yes	No
Have a history of wandering	Yes	No

How many times has the client wandered?

Brief Description of the Circumstances

How did you learn about the Project Lifesaver Program?

Caregiver Information