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2. 

4. The TC Take Me Home program has been developed for residents who may need special assistance if they are alone or in times of emergency. It has been designed for individuals who have difficulty communicating, as well as individuals with Autism, Down Syndrome, developmental or cognitive disabilities as well as senior citizens who may suffer from dementia or Alzheimer's.

   
   

   The program is intended to assist those who are unable to communicate or properly identify themselves in the event they become disoriented and those who may act in a manner that could be misinterpreted by first responders.

   
   

   Families or individuals complete the Take Me Home form, which provides essential information about the loved one with special needs. The form includes information such as height, weight, identifying information, emergency contact information and a current photograph.

   
   

   The information is stored and maintained in a secure database accessible to police officers.

   
   

   If an officer finds someone who is unable to communicate where he or she lives, the officer can search our database and 'Take Home' the individual to their loved one. The system also works in reverse; if a loved ones goes missing, their picture and description is immediately available to first responders.

6. SUBJECT INFORMATION
8. Application Date:*
   Application Date:
10. First Name:*
11. Last Name:*
13. Preferred Name/ Nickname:
15. Date of Birth:
    Date of Birth:
16. Age:*
17. Race:*
19. Sex:*
    -- Select One --MaleFemale
20. Height:*
21. Weight:*
22. Hair Color:*
24. Eye Color:*
25. Glasses?*
    -- Select One --YesNo
27. Other Distinguishing Marks or Characteristics:
29. Home Address:*
31. Home Address 2:
33. City:
34. State:
35. Zip Code:
37. Phone Number:*
39. Disability:*
    -- Select One --Alzheimer'sAutisicDeafMentally DisabledOther
40. Enrolled in School?
    -- Select One --YesNo
42. Other Relevant Information:
46. EMERGENCY CONTACT INFORMATION
48. 1.) First and Last Name:*
49. Relationship:*
51. Cell Number:*
52. Alternate Contact Number:
54. Address:*
56. City:*
57. State:*
58. Zip Code:*
60. 2.) First and Last Name:
61. Relationship:
63. Cell Number:
64. Alternate Contact Number:
66. Address:
68. City:
69. State:
70. Zip Code:
74. Are there special interests (outside of their residence) that your loved one is drawn to? (Examples: trains, water, woods, parks, malls, traffic, etc.):*
76. Has your loved one ever run away or been reported as missing? If so, where were they found?*
78. Is your loved one verbal or nonverbal? Please explain:*
80. Is your loved one verbal or nonverbal? Please explain:
82. Does your loved one have any triggers? (Examples: lights, sirens, loud radio noise, etc.)*
84. If your loved one becomes confrontational, how could Police or Fire/EMS personnel calm them without your presence?*
86. Name of caregivers, parents, grandparents or other family members involved in your loved one’s life:*
88. Please provide in detail any other important information that might aid us in assisting your loved one:
92. Please provide a valid e-mail address to receive reminders to update your photos:
94. Email Address:*
95. Picture:*
    Please submit current Photo
99. Please review your answers carefully and read the following statement before submitting this application.

    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. Electronic Signature Acceptance*

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

     1. YES
105. Electronic Signature
107. 
Leave This Blank:


109. 1. Receive an email copy of this form.
110. Email address

     This field is not part of the form submission.

111. Submit

* indicates a required field