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2. 
4. PLEASE ONLY COMPLETE THIS FORM IF:
   • The subject is currently registered in the Take Me Home program, and
   • You are updating the contact information and photo.
6. Application Date:*
   Application Date:
8. First Name:*
9. Last Name:*
10. Name to Call Me:
12. Date of Birth:*
    Date of Birth:
13. Hair Color:*
14. Eye Color:*
16. Race:*
17. Sex:*
    -- Select One --MaleFemale
18. Height:*
19. Weight:*
21. Home Address 1:*
23. Home Address 2:
25. City:*
26. State:*
27. Zip Code:*
    -- Select One --750337503475035
28. Telephone:
30. Disability:
    -- Select One --Alzheimer'sAutisticDeafMentally DisabledOther
31. Other:
33. Is your Loved One Approachable?*
    -- Select One --YesNo
34. Tips for Approching?
36. Special Fear or Attractions?
38. Other Relevant Information:
42. EMERGENCY CONTACT INFORMATION
44. 1) First and Last Name:*
45. Phone:*
46. Cell:*
48. Address: *
    City, State and Zip Code
49. Relationship:*
53. 2) First and Last Name:
54. Phone:
55. Cell:
57. Address:
    City, State and Zip Code
58. Relationship:
62. 3) First and Last Name:
63. Phone:
64. Cell:
66. Address:
67. Relationship:
69. 1. What is the address where your loved one spends the majority of their time?*
71. 2. Diagnosis of the registered person:*
73. 3. Physical description of the registered person:
75. Height:*
76. Weight:*
77. Hair Color:*
79. Eye Color:*
80. Race:*
81. Gender: *
83. Glasses? *
    -- Select One --YesNo
85. 4. Is there a special interest (outside of their residence) that your loved one is drawn to? (For example: trains, water, woods, parks, malls, traffic, etc.).*
87. 5. Has your loved one ever ran away or been reported as missing? If so, where was he/she found?*
89. 6. Is the registered person verbal or non-verbal? Explain in detail.*
91. 7. Does the registered person fear Police or Fire-EMS personnel or emergency vehicles? Explain in detail.*
93. 8. Name of care givers, parents, grandparents or other family members involved in your loved one’s life.
95. 9. If your loved one becomes confrontational, how could Officers or Rescue Personnel calm them without your presence?*
97. 10. Please explain in detail any other important information that we may need to know that might assist us in not triggering a violent response from your loved one.
99. 11. Does your loved one have any triggers ie: lights, sirens, loud radio noise?
101. 12. Please explain in detail any other important information we may need to know that might assist us in assisting your loved one.
105. Please provide a valid e-mail address to receive reminders to update your photos
107. e-Mail:*
108. Picture:*
     Please submit Photo

112. Please review your answers carefully and read the following statement before submitting this application.
114. 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.
116. Date:*
     Date:
118. Acceptance: *

     1. YES

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


122. 1. Receive an email copy of this form.
123. Email address

     This field is not part of the form submission.

124. Submit

* indicates a required field