Form Center • Southlake, TX • CivicEngage

Introduction

Take Me Home Program
Take Me Home 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. The form below requires information such as a current digital picture, demographic information and caregiver contacts.
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First Name*
Last Name*
Relationship to Child or Adult*
Subdivision Name*
Address*
City
State
Zip Code
Primary Contact Phone Number*
Other Contact Phone Number
Email Address for Primary Contact to Receive Update Information?*
We will send you an email reminder when it is time to submit an updated photo and information.
Assisted Living / Nursing Home Name
Caregiver Contact Information - Secondary Parent or Legal Caregiver (if applicable)
First Name
Last Name
Relationship to Child or Adult
Address (if different than above)
City
State
Zip Code
Secondary Contact Phone Number
Other Secondary Contact Phone Number
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Favorite attractions or locations where the individual may be found?*
Behaviors or characteristics that may attract the attention of responders?*
i.e. wonders to a favorite place
Favorite toys, objects, music, discussion topics, likes or dislikes?*
Does the individual carry any identification information?*
i.e. ID card or medical alert bracelet
Medical ID/Alert #
Please list identification number if applicable.
Does the individual have any tracking information?*
i.e. EmFinders or LoJack SafetyNet Transmitter number?
Please list any current medications.*
Preferred communication if non-verbal?*
1. Sign Language
2. Picture Boards
3. Written Words
4. No Preference
Additional notes or comments.
Is this the first time to provide information or is this an update to existing information?
1. New Submission
2. Update to Existing
Electronic Signature*
1. Yes
My electronic response of 'YES' constitutes an affirmative under oath that I am legally responsible for the person names above for whom I have provided information, and that I consent to have this information shared among law enforcement personnel for enrollment in the 'Take Me Home' program.
Upload Recent Photo of Youth or Adult.*

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