2. 
5. Application Date*
   Application Date
8. First Name*
9. Last Name*
11. Name to Call Me*
13. Address*
15. City*
16. State*
17. Zip*
19. Date of Birth*
    Date of Birth
20. Hair Color*
21. Eye Color*
23. Sex*
    -- Select One --MaleFemale
24. Race*
25. Height*
26. Weight*
28. List any disabilities*
30. Is your loved one approachable?*
    -- Select One --YesNo
31. Does your loved one wear glasses?*
    -- Select One --YesNo
35. Emergency Contact Information
37. 1. First Name*
38. Last Name*
40. Address*
42. City*
43. State*
44. Zip*
46. Phone Number*
47. Relationship*
51. 2. First Name
52. Last Name
54. Address
56. City
57. State
58. Zip
60. Phone Number
61. Relationship
65. 3. First Name
66. Last Name
68. Address
70. City
71. State
72. Zip
76. Address where registered person spends the majority of his/her time*
78. City
79. State
80. Zip
82. Diagnosis of registered person?*
84. List of all medications taken by registered person*
86. Please list any medications that are time sensitive
88. Please list any special interests (outside of their residence) that the registered person may be drawn to. (Examples; trains, water, woods, parks, malls, traffic, etc)*
90. Has the registered person ever run away or been reported missing? If so, where was he/she found?*
92. Is the registered person verbal or non-verbal? Please explain in detail*
94. Does the registered person fear Police or Fire-EMS personnel or emergency vehicles? If so, please explain in detail?*
96. Name of care givers, parents, grandparents, or other family members involved in the registered persons life. *
98. If the registered person becomes confrontational, how could Officers or Rescue Personnel calm them without your presence?*
100. Does the registered person have any triggers? (Examples; sirens, lights, loud noises) Please explain in detail*
102. Please explain in detail any important information that could be used to help assist in not triggering a violent response from the registered person. *
104. Please provide any further details that may assist in helping the registered person.
108. Please provide a valid email for reminders to update photos of the registered person.*
109. Photo*
113. Please review your answers carefully and read the following statement before submitting this application.
115. 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.
117. 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:


120. 1. Receive an email copy of this form.
121. Email address

     This field is not part of the form submission.

122. Submit

* indicates a required field