Fillable HOME Prosper Police Department (Town of Prosper)

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HOME Prosper Police Department (Town of Prosper)

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BROWSE TOWN OF PROSPER (TX) FORMS

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Prosper Police Department
Doug Kowalski, Chief of Police
Professional Service Since 1821
“TAKE ME
HOME”
PROJECT
SUBJECT INFORMATION
Name: ______________________________ Name to Call Me: ________________
Date of Birth: _______________ Hair Color: _______________ Eye Color: __
Race: ___________ Sex: ___________ Height: ___________ Weight: ___
Home Address: _____________________________________________________
City: ______________ State: ____ Zip Code: _________ Telephone: ________
Disability: Alzheimer’s Autistic Deaf Mentally Disabled Other: __________
Organization: ARC Council on Aging Autistic Foundation Other: _________
Email Address:_______________________________________________________
Verbal or Nonverbal: __________________ If nonverbal, form of communication:
____________________________________________________________________
Known to roam? _____________ If so, where have they gone to before: _______
____________________________________________________________________
Comforts:___________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Dislikes:_____________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Person filling out form: ___________________ Relationship to person________
EMERGENCY CONTACT INFORMATION
1
Name:
_________________________________________
Phone: _________________
Cell Ph:_________________
Address:
Relationship:
2
Name:
_________________________________________
Phone: _________________
Cell Ph:_________________
Address:
Relationship:
3
Name:
_________________________________________
Phone:__________________
Cell Ph: ________________
Address:
Relationship:
4
Name:
_________________________________________
Phone: _________________
Cell Ph:_________________
Address:
Relationship:
5
Name:
_________________________________________
Phone: _________________
Cell Ph:_________________
Address:
Relationship:
My signature below constitutes an affirmation 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.
_____________________________________
Signature / Date
_____________________________________
Witness
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HOME Prosper Police Department (Town of Prosper)

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Completed 24 February 2021

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