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2. Take Me Home Program

   The Take Me Home program is a FREE service available for all residents of Forney, for adults and children who may have difficulty communicating due to a developmental or cognitive disability. The database is maintained by the Forney Police Department. It is only accessible to law enforcement personnel and may include a photograph, disability information, physical description, and emergency contact information. If a person in the Take Me Home program is encountered by a police officer dispatched by Forney, personnel can access the database and quickly retrieve critical information that can help in communicating with the individual and a safe return to the caregiver.

4. Subject Information
6. Name*
7. Name to Call Me
8. Date of Birth*
   Date of Birth
10. Hair Color*
11. Eye Color*
12. Race*
14. Sex*
15. Height*
16. Weight*
18. Home Address*
19. State*
20. City*
22. Zip Code*
23. Telephone Number*
24. Disability

    1. Alzheimer's
    2. Autism Spectrum Disorder
    3. Other
26. If Other, please indicate disability below:
27. Intellectual/Development Disability
29. Please attach a photo of applicant
31. Emergency Contact Information
33. Name
34. Phone
35. Address
37. Relationship with Applicant
39. Emergency Contact #2
40. Phone
41. Address
43. Relationship with Applicant
45. I verify 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.*
47. Information Specific to the Individual
49. Favorite attractions or locations where the individual may be found: (Include any friends or relatives in the area)
51. Atypical behaviors or characteristics of the individuals that may attract attention:
53. Individual’s favorite toys, objects, music, discussion topics, likes, or dislikes:
55. Method of preferred communication (If nonverbal: Sign language, picture boards, written words, etc.):
57. Identification information (i.e. Does the individual carry or wear jewelry, tags, ID card, medical alert bracelets, etc.?):
59. Likes/Dislikes including approach and de-escalation techniques:
61. Once enrolled, each applicant will receive two Take Me Home program stickers. (Pictured Below)
63. 
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field