Police

Take Me Home Form

Subject Name

First Name *

Middle Initial

Last Name *

Home Address

Address Line One *

Address Line Two

City *

State *

Zip *

Race *

Sex *

Date of Birth *

Height *

Weight *

Hair Color *

Eye Color *

TX ID/DL# *

Other Notable Characteristics *

Daytime Location (School, Caretaker, Etc.) *

Disabilities *

Emergency Contact

First Name *

Middle Initial

Last Name *

Relationship *

Address

Address Line One *

Address Line Two

City *

State *

Zip *

Phone Number *

Physician Name

First Name *

Middle Initial

Last Name *

Physician Address

Address Line One *

Address Line Two

City *

State *

Zip *

Physician Phone *

Email Address to Receive Updates *

Current Photo of Individual *

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Locations where the individual may be found *

Atypical behaviors or characteristics of the individuals that may attract the attention of responders: *

Individual’s favorite toys, objects, music, discussion topics, likes or dislikes: *

Method of preferred communication (if nonverbal: Sign language, picture boards, written words, etc.): *

Likes/Dislikes (including approach and de-escalation techniques): *

Take Me Home Program Agreement

Checking the box below constitutes an affirmative under oath that I am legally responsible for the person named 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.

I have read and agree to the Take Me Home Program Agreement

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