North Arlington Police

    North Arlington Police Department

    214 Ridge Rd, North Arlington, New Jersey 07031

    Phone: 201-991-4400 Ext: 0

    Fax: 201-991-4068

    Safely Back Home Enrollment Form

    Thank you for taking the initiative to be a part of the North Arlington Safely Back Home Program

    Safely Back Home™ is an innovative program that provides additional peace of mind to families and caregivers of people who wander. The Safely Back Home™ patent-pending process uses ID information imprinted on personal garments to help the public and the police assist an individual who has become lost.

    The Safely Back Home™ Program was developed in response to a need to provide assistance to individuals who are incapable of providing identifying information in situations where they become lost.

    When an individual who wanders and appears lost is wearing a Safely Back Home™ imprinted garment, the concerned person who notices them can quickly contact NAPD with location details and a rescue ensues.

    The Safely Back Home™ program enables police and first responders to understand how to communicate effectively with your family member, allowing your family member to remain calm during their rescue.

    Families/Caregivers provide medical and personal information about the family member. All information remains confidential and privacy protected. Wherever your family member is wandering (in NJ/USA) – police departments are able to electronically share this information in coordinating the rescue.

    Applicant Information

    The enrollment application should be filled out by the family member/caregiver (the Authorized Representative) on behalf of the individual (the Applicant) who will be enrolled in the NAPD Safely Back Home program. Providing this detailed information in advance of any need ensures an efficient and speedy response by Emergency Services personnel. Please be as thorough and complete as possible.

    ***Please provide a current PHOTO of APPLICANT here***

    Upon receipt and review of the enrollment application, a NAPD Safely Back Home ID number specific only to the applicant will be issued. The family member/caregiver will receive this NAPD Safely Back Home ID# via email. The family member/caregiver will also receive notification that the application has been accepted.

    IMPORTANT: All information submitted on the enrollment form will be kept confidential and stored in a secure database maintained by the NAPD.

    This application is divided into three sections:
    • The first section requires information about you, the Authorized Representative.
    • The second section is for additional emergency contact information. Should you not be available or if we are unable to get in touch with you, only an authorized person(s) listed on the enrollment form will be contacted.
    • The third and last section of the application is where you will provide information about the individual being enrolled, the Applicant. All sections are to be filled out by you, the Authorized Representative.





    Section 1: Authorized Representative Information (PRIMARY CONTACT)

    Section 2: Secondary Emergency Contact Information

    If an emergency arises and we are unable to reach the authorized representative, we will contact the individual(s) you designate below. Please provide contact information for two additional people that the NAPD may contact..

    Section 3: Applicant’s Information - Personal Data


    Is the Applicant Verbal or Non-Verbal ? VerbalNon-Verbal

    Does the Applicant live alone? YesNo

    Does the Applicant understand English? YesNo

    If NO, what language is understood?

    Spoken word onlyWritten and spokenSign Language

    Physical Description

    Other relevant Medical Conditions (please check all that apply):

    BlindDeafNo Sense of DangerProne to SeizuresCognitive ImpairmentNone of the above

    Medical Diagnosis

    Applicant’s specific diagnosis?

    Does the applicant wear glasses?

    YesNo     Contacts?YesNo         Sunglasses?YesNo

    If the applicant wears corrective eye wear, what degree of vision does he/she have without the eye wear? NonePoorFair

    Does the Applicant wear a hearing aid? YesNo      If yes, Left EarRight Ear

    What type of hearing does he/she have without the hearing aid? NonePoorFair

    Does APPLICANT have any ALLERGIES to medication/food? YesNo

    If yes, please list those allergies to medication/food:


    Health/Behavioral Information

    Health, medical, or related physical handicap issues?

    Please list medications taken regularly:           None

    Does the Applicant know his/her name? YesNo

    Will applicant respond if called by his/her name? YesNo

    Would the Applicant attempt to or have the ability to communicate if lost or hurt? YesNo

    How would he/she do this?

    How would you rate the Applicant’s overall ability to communicate?

    What name does the Applicant call the family member or friend with whom they have the closest emotional attachment?

    Does the Applicant recognize familiar persons and faces? YesNo

    Does the Applicant have a fear of people, pets / animals, noises, shouting; anything else?

    Do you have any suggestions for what the First Responder/Police Officer should say to the Applicant to help keep him/her calm as the First Responder/Police Officer approaches them?

    Method of Preferred Communication One (If verbal: preferred phrases, words, sounds, songs they respond to):

    Method of Preferred Communication Two (If nonverbal: Sign Language, written words, picture boards, etc.):

    How will the Applicant react if approached by a uniformed officer?

    Can the Applicant travel on his/her own to familiar or favorite locations?

    List favorite attractions or locations where the Applicant may be found:


    Applicant’s favorite objects, music, TV shows/characters, sports teams/players, discussion topics, likes or dislikes:

    Items applicant would carry/wear that provide comfort or may have a sentimental value (Example: photos, cell phone, book, favorite hat, watch, jewelry or other object that provides comfort to them.)


    When outside, would the Applicant mostly stay on roadways? YesNo

    Does the Applicant drive a car? YesNo

    If so, what is the:

    Would the Applicant wander to parks/go into wooded areas? YesNo

    Would the Applicant most likely wander during the: DayNightBoth

    Please provide the names and addresses of people the Applicant may head toward:

    Are there any locations that have a special or significant attraction to the Applicant? YesNo

    Please list most recent locations:

    If there were any prior instances of wandering, where was the Applicant found?:

    General Demeanor: OutgoingQuiet

    Talks to strangers: YesNo

    Identification Information. (Does the Applicant carry or wear jewelry, tags, ID card, medical alert bracelets, etc?):
    Please explain:

    Tracking Information (Does the Applicant have a Project Lifesaver number or other tracking device number?): YesNo
    If yes, please enter the Project Lifesaver ID number or other tracking device number:


    I, the undersigned, for myself and on behalf of the Applicant named above, do hereby authorize the North Arlington Police Department to release the above information in response to emergency calls regarding the Applicant and do further agree to indemnify and hold harmless the North Arlington Police Department, Safely Back Home, and its respective employees, agents, officers and directors from any and all claims (other than willful misconduct) arising out of participation in the North Arlington Police Department Safely Back Home program or the release of the above information.

    Furthermore, I hereby represent and warrant to the North Arlington Police Department and Safely Back Home that I have full power and authority, as the duly authorized representative of the Applicant named above, to enroll and act on his or her behalf.

    Authorized Representative Signature (Typed)