Form Center

2. Silver Citizen Database
   The Little Elm Police Department has developed a Senior Citizen database that stores information should an urgent matter arise that involves one of our senior citizens. If there is anyone in your life that you would like included in this database, please take a moment to register them. Officers will use the information to assist in locating a lost citizen or any other urgent situation. A recent photo of the senior citizen is required. The form can be completed electronically, or in person at the Little Elm Police Department (88 W. Eldorado Pkwy., Little Elm, TX 75068. A recent photo of the senior citizen will be required. Contact the Community Service Division at communityservices@littleelm.org 972-377-1885 with any questions.
4. Upload Most Recent Photo
5. Upload Most Recent Photo
7. First Name *
8. Last Name*
9. Race/Ethnicity*
11. Gender*

    1. Male
    2. Female
12. Age (if known)
13. Date of Birth (if known)
    Date of Birth (if known)
15. Street Number*
16. Street Name*
17. Street Type*
18. Apt #
20. City*
21. State*
22. Zip*
24. Neighborhood or Subdivision
    For Example: Villages of Woodlake, Sunset Point
26. Phone Number
27. Alternate Number
29. Closest Relative/Caretaker Name
30. Closest Relative/Caretaker Phone Number
32. Does the Individual Wear Glasses?

    1. Yes
    2. No
33. Does the Individual Use a Walker?

    1. Yes
    2. No
34. Does the Individual Use a Wheelchair?

    1. Yes
    2. No
36. Is the Individual Deaf?

    1. Yes
    2. No
37. If so, Do They Know Sign Language?

    1. Yes
    2. No
39. Does the Individual Suffer from Dementia or Alzheimer's Disease?

    1. Yes
    2. No
40. Please List Any Other Known Health Condition:
42. Does the Individual Drive?

    1. Yes
    2. No
43. Make of Car
44. Model of Car
45. Color of Car
47. Driver's License Number and State
48. Alternate ID Number
50. Additional Details
    Please provide any other useful information that may be helpful, such as favorite places to go, any schedules they keep, friends, favorite clothing, hobbies, etc.
Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field