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   Unaccompanied Minor and Separated Child Report Form
Date/time:
*Shelter Name: 		Incident/DR#:
*Shelter phone number:
Type of Child
Unaccompanied Minor                                 Separated Child
Name (Last, First, Nickname):    
* Date of birth (or approx. age:)     Gender:
Home number:
Cell number: 		Email address:
Is the minor non-verbal/unable
to self-identify?:
Home address:

Primary language spoken:     Secondary language spoken:
*Location where minor was found or separated from parent/guardian:
 

Minors's Physical Description
Clothing:
 Hair color: Eye color:
Weight: Heigth: Build:
Race: Complexion: Hair Style:
Distinguishing marks (moles, scares, tattoos):
 Items carried:
 Eye glasses?
Red Cross Workers Responsible for Supervising the Minor (Unaccompanied Minor ONLY)
Red Cross disaster worker #1 Name: Cell Phone:
Red Cross disaster worker #2 Name: Cell Phone:


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   Unaccompanied Minor and Separated Child Report Form
Presumed Parent / Guardian Information
Name #1: Home phone:
Cell phone:
Email:
Name #2: Home phone:
Cell phone:
Email:
Law Enforcement
Has local law enforcement been notified?
 Law Enforment Contact Information
Date/time law enforcement notified:

 Name of ARC disaster worker who contacted law enforcement:
Cell Phone number:
Notes:
National Center for Missing and Exploited Children (NCMEC)
Has the unaccompanied minor been registered on
NCMEC’s UMR?: 		Has the separated child been reported to NCMEC?:
Date/time of NCMEC contact:

NCMEC contact information:

 Name of ARC disaster worker who contacted NCMEC:


Cell Phone number:
Notes:  
Transfer/Reunification Plan
Name/agency to transfer/reunify minor to: Phone number:
Anticipated date/time of transfer/reunification: Actual date/time of transfer/reunification:
Name of law enforcement officer who approved plan:
Badge number:
DCS JT-F RES Unaccompanied Minor and Separated Child Report Form V.1.0.2016.05.16
[HTML V 1.0 American Red Cross Gold Country Region 2017.01.23]