Find My Family Member

INSTRUCTIONS:

Please answer all the questions as best as you can, and click on the "Submit Your Responses" button at the bottom of this page. We won't let you leave some of the questions blank. These are marked with a red asterisk.*

Please provide the following:

I AM LOOKING FOR MY FAMILY MEMBER WITH A DISABILITY

Please enter as much information as you can about your family member with a disability.

1. What is your missing family member's full name?

   First: *
   Middle:
   Last: *
   Suffix (Jr,Sr,III):

2. When was your family member born? (mm/dd/yyyy) (If you don't know the month and day, you can leave them blank. You have to put in the year: *

   01 02 03 04 05 06 07 08 09 10 11 12 / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /

3. Your family member is: (check one) *

   Male
   Female

4. Your missing family member's ethnic origin is: (check one) *

   Caucasian
   African American
   Latino
   Indian/Asian
   Pacific Islander
   American Indian
   Other (please specify)

5. Enter the city where your family member was born: *

6. Enter the main zip code of the city where your family member was born (find zip codes): *

7. Zip code of last known place your family member lived (find zip codes):

8. If you aren't sure of the last known place, and want to enter a second one, enter it here (find zip codes):

9. If you aren't sure of the last known place and want to enter a third one, enter it here (find zip codes):

10. Year of last contact (yyyy): *

11. Name of the last institution or care facility where your family member with disabilities was living:

12. Use this space to tell your story about your family member and provide as much detailed information as possible. You can include a physical description, like the color of eyes and hair and what they look like, as well as anything else you know or remember about them:

THANK YOU!

Click on the "Submit Your Responses" button below to send your information. If you have left anything out, you can go back and fill it in.