Take Me Home Registration Form

Take Me Home Program

Person Information

Name *

Name to Call Me *

Date of Birth *

Month

Day

Year

Hair Color *

Eye Color *

Race

Sex (M or F) *

Height *

Weight *

Home Address *

City: *

State *

This sign up form is intended for Kansas residents.

Zip Code *

Home Phone # *

Disability

Treatment Facility (if applicable)

Medication

Disclaimer

The information of the person on this form will be entered into the Johnson County Sheriff's Office Take Me Home program within the next 30 days.

Please Note: Should there be any changes, it is the responsibility of the legal guardian or representative to notify the Sheriff's Office so that the program will contain the most up-to-date information.

Helpful Information for the Take Me Home Candidate

Points of interests or locations the individual may like to go to

Atypical behaviors or characteristics of the candidate they might display

Interests that might engage them (ex. Likes, dislikes, music, toys, ect.)

How do they like to communicate (ex. Verbal phrases they might respond to, sign language, written word, cell phone apps, etc.)

Any form of identification carried on them (ex. Medical bracelets, ID card, etc.)

Emergency Contact Information

Main Emergency Contact

Name *

Relationship *

Address *

Home # *

Cell #

Work/Daytime #

E-mail

Other Emergency Contacts

Name

Relationship

Address

Home #

Cell #

Work/Daytime #

Other Emergency Contacts

Name

Relationship

Address

Home #

Cell #

Work/Daytime #

Other Emergency Contacts

Name

Relationship

Address

Home #

Cell #

Work/Daytime #

Photo Attachment

Please attach a current photo

Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png.

Requester Information (Please Enter your name and contact information)

Name *

Phone Number *

Leave this field blank

What code is in the image? *

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Take Me Home Registration Form

Take Me Home Program