Bring Me Home Program

2. By providing detailed information below about the registrant, public safety personnel will be able to quickly access your loved one's information in the event they need help returning home. All data is confidential and only accessible by public safety personnel.

4. Registrant Basic Information
6. First Name*
7. Middle Name
8. Last Name*
10. Nicknames
12. Date of Birth*
14. Gender*
16. Home Address*
18. City*
19. State*
20. Zip Code*
22. Phone*
24. Is registrant normally approachable?*

    1. Yes
    2. No
    3. Other
25. If you selected other
27. Is registrant employed?

    1. Yes
    2. No
28. Is registrant enrolled in school?

    1. Yes
    2. No
30. Please list registrant's disabilities*
32. Other relevant information
34. Registrant Physical Description
36. Hair Color
37. Eye Color*
39. Height*
40. Weight*
41. Race*
43. Glasses?*

    1. Yes
    2. No
45. Other physical characteristics
47. Emergency Contact
49. Full Name*
50. Relationship*
52. Address*
54. Address Line 2
56. City*
57. State*
58. Zip Code*
60. Home Phone*
61. Work Phone*
62. Cell Phone*
64. Registrant Details
66. Has registrant ever gone missing? If so, where were they found?*
68. What are registrant's favorite locations and/ore objects?*
70. Does registrant fear police officers, fire/EMS personnel, emergency vehicles, lights, sirens, loud radio noise, shouting, running, or dogs?*
72. Does registrant have any other triggers or fears?*
74. Does registrant display atypical behaviors or characteristics that may attract the attention of the first responders?*
76. What is registrant's preferred method of communication?
78. Is registrant verbal or non-verbal?*

    1. Verbal
    2. Non-verbal
80. Please explain in detail any information that will help officers and rescue personnel approach and calm the registrant.*
82. Registrant Photo*
83. Approximately when was this photo taken?*
85. Bring Me Home Program Enrollment Signature
87. Are you legally responsible for the person named above as registrant?*

    1. Yes
    2. No
89. Follow-up Information
91. Initial Entry or Update?

    1. First time to provide information
    2. Update to previously reported information
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93. Submit

* indicates a required field