**Your E-mail

** Police Event Number

** Date Missing
MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985

CHILD'S PROFILE

Picture of Child

**Age
Age123456789101112131415161718192021

**Child's Name

Alias/Nickname

** Date of Birth
MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011

** Street Address

** City

** State

** Zip

** Gender
 Male  Female

** Race

** Height

** Weight

** Eye Color

** Hair Color

** Skin Color

Unique Characteristics (piercings, tattoos, scars, braces, glasses, acne, etc.)

Child was last seen wearing

What did child take with him/her?

Child's hobbies, interests and/or hangouts

** School child attends or attended

Was school notified?
 Yes No

** Does child have truancy problem?
 Yes No

Truancy warrant issued for child?
 Yes No

** Has child run away before?
 Yes No

How many times?

What is the longest time child was ever gone?

Circumstances

How did you locate child?

What medications are child taking?

Does child have medication(s) with him/her?
 Yes No Don't Know

Describe child's mental state

Is child under doctor's care?
 Yes No Was in the past

Diagnosis

Doctor's name

Phone number

Does child have cell phone with him/her?
 Yes No Possibly

Is child a victim of abuse?
 Yes No Possibly

Please explain:

Does child use illegal drugs?
 Yes No Possibly

Does child use alcohol?
 Yes No Possibly

Does child chat online?
 Yes No Possibly

Does child use telephone chat line?
 Yes No Possibly

Is child involved in prostitution?
 Yes No Possibly

Is child involved in gang?
 Yes No Possibly

Does child have vehicle?
 Yes No

Whose vehicle is it?

License Number

Description of Vehicle

** Where was child last seen?

Why did child disappear?

Who do you think child is with?

Description of Companion

Address

Phone

LAW ENFORCEMENT INFORMATION

** Name of Police Department

Detective's Name

** Is child on probation
 Yes No

If yes, what for?

Name of Parole Officer

Phone

** Has warrant been issued for child?
 Yes No

** Has child ever been arrested?
 Yes No

When?
MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay12345678910111213141516171819202122232425262728293031Year198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011

What for?

PERSONAL INFORMATION

Would you like your child to receive counseling?
 Yes No

** Who has custody of child?

** Relationship to Child

** Your Name

** Address

** Home Phone

Cell Phone

Place of Employment

Is it okay to call you at work?
 Yes No

Work Phone

Other Adult in the Home

Relationship to Child

Place of Employment

Work Phone

Other Biological Parent (if applicable)

Address

Home Phone

Cell Phone

Place of Employment

Work Phone

Others Present in Child's Home

Primary Language

Do you speak English?
 Yes No

OPTIONAL (This part will help us to apply for funding.)

What is your total yearly income?
 $30,000+ Under $30,000 Under $20,000 Under $10,000

How many people are living in your household?

Consent and Release Form

I authorize Nevada Child Seekers and its authorized agents to assist in the search for my missing child(ren).

Consent is hereby granted Nevada Child Seekers to use photographs of my child(ren) along with details concerning the disappearance and search for the child(ren).

Nevada Child Seekers may use such photo and information on local and national television, newspapers, flyers, poster, magazines, or any other distribution source.

Further I consent to the investigation and confirmation by the above agency of any/all information I have given or will give to assist in the search of my child(ren).

I agree to release, indemnify, and hold harmless Nevada Child Seekers, its directors, officers, employees, volunteers, and authorized agents from any and all liability, claims and causes of action which may result or arise from the release of pictures, information or details concerning the disappearance of the child(ren).

I agree to the following consent and release:
 Yes No

Code Verification: