Incomplete applications will not be processed! ** denotes a required field
INFORMATION ABOUT YOU
Your email address** :
Reporting Parent Full Name** :
Address** :
City** :
State** :
Use Postal Abbreviation
ZIP/Postal Code** :
Daytime Phone #** :
(i.e., (###)###-####)
Collect phone calls:
I
CAN
CAN'T
accept collect calls to day #.
Evening Phone #** :
(i.e., (###)###-####)
Collect phone calls :
I
CAN
CAN'T
accept collect calls to eve #.
FAX #:
(i.e., (###)###-####)
Other Phone #:
(i.e., (###)###-####)
Parent's DOB** :
DD/MM/YY (i.e., 31/01/95)
Parent's SSN#** :
as ###-##-####
Legal relationship to child** :
Custodial Mother
Custodial Father
Non-Custodial Mother
Non-Custodial Father
Legal Guardian
INFORMATION ABOUT YOUR MISSING CHILD
Type Missing** :
Runaway
Runaway with medical emergency
Abducted non-relative
Abducted relative
Other / Unknown
Full Name of Child** :
Nickname of Child:
Date of Birth** :
DD/MM/YY (i.e., 31/01/95)
Height** :
feet
inches
Weight in pounds** :
lbs.
Child's SSN#** :
as ###-##-####
Gender** :
Male
Female
Race** :
American Indian
Arab
Asian
Black
Caucasian
Hispanic
Indian
Eye color** :
Black
Blue
Brown
Gray
Green
Hazel
Hair color** :
Auburn
Bald
Black
Blonde
Sandy Blonde
Dark Blonde
Dirty Blonde
Platinum Blonde
Strawberry Blonde
Brown
Dark Brown
Light Brown
Gray
Red
Salt & Pepper
Silver
White
Body build:
Average
Medium
Large
Heavy
Slender
Slim
Petite
Small
Date Last Seen** :
DD/MM/YY (i.e., 31/01/95)
Time Last Seen** :
am
pm (i.e., 4:30)
CIRCUMSTANCES
Where & How Child Last Seen
(clothing & other items taken, etc) :(scars, tattoos, body piercing, birthmarks, etc) :(give name, address, vehicle info, description, why thought to be with, etc.) :
Please note that if you need more than 250 characters for this information (above)
please send email to: missing@childsearch.org (with your child's name as the subject)
POLICE REPORT INFORMATION
Police Department Reported to ** :
Police Contact Person ** :
Phone # for Police Contact Person ** :
(i.e., (###)###-####)
Police Case # ** :
NCIC # or CPIC # ** :
Felony Warrant(s) Issued?
Yes No
If Yes - Against Whom?
Quality Photograph of Child Sent** :
Attached now: by Mail
by Email (scanned .jpg image) to photos@childsearch.org
I am aware that by submitting this application for assistance, I am granting irrevocable rights to
Child Search® to publish photographs of my child, myself, other members of my family
and accounts in any form of media both before and after recovery of my child for purposes of locating
my child and/or any fund raising or public relations purposes that Child Search® may have.
Please type "QPWB28 "(without the quotation marks) into the box on the right:
