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2. 
6. SUBJECT INFORMATION
8. Application Date:*
   Application Date:
10. First Name:*
11. Last Name:*
12. Preferred Name/Nickname:
14. Date of Birth:*
    Date of Birth:
15. Age:*
16. Race:*
17. Sex:*
    -- Select One --MaleFemale
19. Height:*
20. Weight:*
22. Hair Color:*
23. Eye Color:*
24. Glasses? *
    -- Select One --YesNo
26. Other Distinguishing Marks or Characteristics:
28. Home Address 1:*
30. Home Address 2:
32. City:*
33. State:*
34. Zip Code:*
    -- Select One --750337503475035
35. Telephone:
37. Disability:*
    -- Select One --Alzheimer'sAutisticDeafMentally DisabledOther
38. Other:
40. Enrolled in School?
    -- Select One --YesNo
41. If Yes, Name of School and City:
43. Other Relevant Information:
47. EMERGENCY CONTACT INFORMATION
49. 1) First and Last Name:*
50. Phone:*
51. Cell:*
53. Address: *
    City, State and Zip Code
54. Relationship:*
56. 2) First and Last Name:
57. Phone:
58. Cell:
60. Address:
    City, State and Zip Code
61. Relationship:
63. 3) First and Last Name:
64. Phone:
65. Cell:
67. Address:
68. Relationship:
72. Are there special interests (outside of their residence) that your loved one is drawn to? (Examples: trains, water, woods, parks, malls, traffic, etc.)*
74. Has your loved one ever run away or been reported as missing? If so, where were they found?*
76. Is your loved one verbal or nonverbal? Please explain.*
78. Does your loved one fear Police or Fire/EMS personnel or emergency vehicles? Please explain.*
80. Does your loved one have any triggers? (Examples: lights, sirens, loud radio noise, etc.)*
82. If your loved one becomes confrontational, how could Police or Fire/EMS personnel calm them without your presence?*
84. Name of caregivers, parents, grandparents or other family members involved in your loved one’s life.*
86. Please provide in detail any other important information that might aid us in assisting your loved one.
90. Please provide a valid e-mail address to receive reminders to update your photos
92. Email:*
93. Picture:*
    Please submit Photo

97. Please review your answers carefully and read the following statement before submitting this application.
99. My acceptance below constitutes an affirmation under oath that I am legally responsible for the person named above for whom I provided information, and that I consent to have this information shared among law enforcement personnel for enrollment in the Take Me home Program.
101. Date:*
     Date:
103. Acceptance: *

     1. YES

     By Checking YES you are indicating that you have read and agree to the terms and conditions above.
Leave This Blank:


107. 1. Receive an email copy of this form.
108. Email address

     This field is not part of the form submission.

109. Submit

* indicates a required field