Personal Information
Full Name:
Age at Disappearance: Date of Birth:
Other Names:
Last Known Address (Street, Apt., City, State, Zip Code):
Phone: Email:
Hair Color: Eye Color:
Weight: Height:
Gender Identity: Biological Sex (M/F):
Distinguishing Features:
Medical Conditions:
Scars, Marks, Tattoos, Etc:
Is this person enrolled: YesNo Tribe:
Tribal Affiliation:
Was this person homeless or transient at the time of the disappearance?: YesNo
Areas Frequented:
Has this person ever been arrested? YesNo
Provide Dates and Jurisdiction, if possible:
Do you believe this person was the victim of sex or human trafficking? YesNo
If Yes, please explain why:
Information Regarding the Disappearance
Has this person been reported missing to Law Enforcement? YesNo
If interested, please consider filling out WSC’s Law Enforcement Survey. This information will not be released to law enforcement, but will help WSC gather important information about tribal-police relationships that will impact the development of training, program guidelines and best practices
Date of last contact With Family/Friends:
Please list Social Media Accounts, if known
Car Make: Car Model: Car Color:
State Licensed: License plate:
Car's Noticeable Marks or Features:
Contact Information
Name: Email: Phone: Relationship:
Name: Email: Phone: Relationship:
Name: Email: Phone: Relationship:
Law Enforcement Contact (If Applicable)
Officer Name:
Phone: Email:
Case Number: Jurisdiction:
Disclaimer
By providing this information to WomenSpirit Coalition and filling out the “Law Enforcement Reporting Form” I understand that identifying information will be shared on the WomenSpirit Coalition website.Non identifying information (such as age, tribal affiliation, gender, etc) may be shared with governmental and research agencies in an attempt to gather accurate data regarding missing individuals in Indian Country.
Request Assistance - By checking this box, you are requesting assistance in contacting police for your missing loved one. This form will be forwarded to the appropriate law enforcement contact. You will be notified of the agency and someone may contact you regarding this case.
Signature - Check this box in lieu of a signature, authorizing that you have read and agreed to the above disclaimers
WomenSpirit Coalition
10049 Kitsap Mall Blvd Ste. #304
Silverdale, WA 98383
[T] 360 633 7083
[F] 360 633 7080
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