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Missing Child Information: Circumstances which occurred prior to and at the time disappearance. If known, include the motivation for running away. Yes No Has he or she ever run away before? Yes No If yes, provide details (e.g., when, where, length of time missing, location while missing.) Places where the child lived in the past (e.g., name of municipality, state and street address.) 1 E-mail Cell Phone Work Phone Home Phone City Address Relationship First Name Last Name Cell Phone Places (e.g., states, cities) that the child has expressed and interest in visiting or living. No Yes Do you believe that there is any possibility that any family members, friends or others are providing aid to the runaway(s)? Identify possibilities by name and location. Complete the form, save it on your PC and then attach it to an email and send to: [email protected] or fax to 518-457-6965. Runaway Intake Report DOB Child's prior encounters with law enforcement and the courts. Describe circumstances, locations and approximate dates. Drug, alcohol or other chemical dependencies the child may have. Child's general interests (i.e., in or outside of school, sports, online, etc.) If applicable, type of employment last held by the child & the employer's name and address. Person Completing Form: Relationship First Name Last Name Phone E-mail Agency (if applicable) E-mail Social Media Where Last Seen Date Time Fingerprints Available Mother's Maiden Name Legal Guardian of Child: County/Country Zip Code MI: First Name Last Name Has child ever indicated the he or she would run away? Sex State

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Page 1: Runaway Intake Report - NY · PDF fileWork Phone Cell Phone E-mail . County/Country. Home Phone Address City Last Name Relationship. First Name. ... friends or others are providing

Missing Child Information:

Circumstances which occurred prior to and at the time disappearance. If known, include the motivation for running away.

Yes No Has he or she ever run away before? Yes No

If yes, provide details (e.g., when, where, length of time missing, location while missing.)

Places where the child lived in the past (e.g., name of municipality, state and street address.)

1

E-mail Cell Phone Work Phone

Home Phone

CityAddress

Relationship First NameLast Name

Cell Phone

Places (e.g., states, cities) that the child has expressed and interest in visiting or living.

No YesDo you believe that there is any possibility that any family members, friends or others are providing aid to the runaway(s)?

Identify possibilities by name and location.

Complete the form, save it on your PC and then attach it to an email and send to: [email protected] or fax to 518-457-6965.

Runaway Intake Report

DOB

Child's prior encounters with law enforcement and the courts. Describe circumstances, locations and approximate dates.Drug, alcohol or other chemical dependencies the child may have.

Child's general interests (i.e., in or outside of school, sports, online, etc.)

If applicable, type of employment last held by the child & the employer's name and address.

Person Completing Form:

Relationship First NameLast Name

Phone E-mail Agency (if applicable)

E-mail Social Media

Where Last Seen Date Time

Fingerprints Available Mother's Maiden Name

Legal Guardian of Child:

County/CountryZip Code

MI:First NameLast Name

Has child ever indicated the he or she would run away?

Sex

State

Page 2: Runaway Intake Report - NY · PDF fileWork Phone Cell Phone E-mail . County/Country. Home Phone Address City Last Name Relationship. First Name. ... friends or others are providing

Does child speak a regional or foreign accent or language other than English?

Child's strengths and weaknesses (e.g., punctual/tardy, enthusiastic/indifferent)

If yes, provide details. No

Yes

Social MediaE-mail

Cell Phone Work Phone Home Phone

Miscellaneous (i.e.,physical or mental condition)

Physical Characteristics (Scars/ Marks/Tattoo/Piercings/Dentals)

Eyes HairWeightHeightRace

Alias/NicknameSexCounty/CountryState/Zip Code

City

First NameLast Name

Companion Information:

Where Last Seen Date Time

2

NYS Division of Criminal Justice Service - Missing Persons Clearinghouse

80 South Swan Street, Albany, NY 12210 1-800-346-3543

518-457-6965 FAX [email protected] www.criminaljustice.ny.gov

do not authorizeI authorize

The undersigned parent/guardian or spouse (if married student) of hereby requests the information pertinent to the disappearance of the above named child/college student and deemed appropriate for release by the law enforcement agency responsible for the investigation of the said disappearance be published and/or circulated by any method subscribed to by the New York State Division of Criminal Justice Services (DCJS), including the use of photographs. I understand this information will be made available to the public, media, other law enforcement agencies, hospitals, social service agencies, shelters, medical examiners and/or other agencies or organizations involved with missing persons. I understand and agree that any or all information supplied by me shall be truthful and I agree to hold harmless any agency or department using, transmitting, or distributing this information for errors or omissions or commissions occasioned by information I supply. I further agree that a photocopy of this authorization shall have the same effect as the original. If available, DCJS can store and upload his/her fingerprints to the Statewide Automated Fingerprint Identification System to assist with developing lead information.

Additional Narrative Information:

7-2016

MI DOB

OtherReport DateAgency Case #

Cell Phone

Investigating Officer's Name

Telephone

Investigating Police Agency

Investigating Law Enforcement Agency Information:

Street Address

Social Security # Occupation Employer

Describe the child's personality (i.e., friendly, outgoing, withdrawn, shy.)

Medical Problems/Medications Utilized

Parent/Guardian Signature

Was there an ongoing or pending custody dispute?

Relationship between the child's parents (e.g., advisarial/amicable/violent?

E-mail

(Print Name of Child/Student)


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