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2. Applicants Must Reside in the City of North Miami

   Once completed, Our Guardian Program Manager will contact you to move forward.

4. Registrant Information
6. Registrant's Name*
8. Birthday*
9. Sex*
10. Race*
12. Height*
13. Weight*
14. Build*
15. Eye Color*
17. Hair Color*
18. Hairstyle*
20. Mustache*

    1. Yes
    2. No
21. Balding*

    1. Yes
    2. No
22. Smoke*

    1. Yes
    2. No
23. Alcohol*

    1. Yes
    2. No
25. Drugs*

    1. Yes
    2. No
26. Sideburns*

    1. Yes
    2. No
27. Hearing aid*

    1. Yes
    2. No
28. Eye Glasses*

    1. Yes
    2. No
30. If Drugs, what type*
31. Language(s) spoken/understood*
33. Nickname:*
34. If spouse, name*
36. Current Address*
38. Spouse’s name*
39. Spouse

    1. Living

    1. Deceased
41. Registrant diagnosis*
43. Caregiver Information
45. Name*
46. Relationship to Registrant*
48. Address (if different than Registrant)*
50. Primary phone*
51. Secondary phone
53. Email address*
55. Work address*
57. Phone Number*
59. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
61. Electronic Signature
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field