West Branch Police Department Safe Child Program

Vital Information Form

Please submit a new form for each child. When completed, click the submit button and print a copy for your records. A West Branch Police Officer will be in contact with you to arrange photographing/fingerprinting of your child. For more information, please call Police Chief David Bloem at 643-2222 or email.

Your Name:
Your Email:
Child Information
Child's Last Name:
Middle Name:
First Name:
Nicknames:
Age:
Sex:	female male
Height:
Weight:
Race:
Hair Color:
Eye Color:
Special Identifiers: i.e. scars, birthmarks, tatoos, piercings, etc.
Mother
Name:
Address:
Home Phone:
Cell Phone:
Work Phone:
Father
Name:
Address:
Home Phone:
Cell Phone:
Work Phone:
Guardian/Step Parent:
Name:
Address:
Home Phone:
Cell Phone:
Work Phone: