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Safe Watch Program

  1. Police Shield

  2. Lowell Police Department - Safe Watch Program

  3. Please complete the following fields to register an individual for the Safe Watch Program.

  4. Subject's Profile

  5. (e.g. jewelry, tags, ID card, Medic Alert bracelets)

  6. Medical Information

  7. Medical Conditions

  8. (e.g. Sensory or dietary issues; any other relevant medical issues)

  9. Is he/she likely to wander?*

  10. Habits/ Preferences

  11. (e.g. if non-verbal - sign language, pictures, printed words)

  12. Emergency Contact Information

  13. Primary Contact Name

    (Parents/ Guardians/ Care Providers)

  14. Alternate Contact Name #1

  15. Alternate Contact Name #2

  16. For any questions/comments/concerns, please contact Molyka Tieng at MTieng@LowellMA.gov or 978-674-1906.

  17. Leave This Blank:

  18. This field is not part of the form submission.