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2. Subject Information
4. Full Name*
6. Nicknames I will answer to:
8. Data of Birth*
   Enter mm/dd/yyyy
9. Hair color*
10. Eye Color*
12. Sex

    1. Male
    2. Female
    3. Other
    4. Prefer not to answer
13. Race
14. Height
15. Weight
17. Home Address
19. Address1
21. Address2
23. City
24. State
25. Zip
27. Telephone
29. Condition*

    1. Alzheimer's
    2. Autism
    3. Mental Illness

    1. Deaf
    2. Other
31. Emergency Contact Information 1:
33. First Name
34. Last Name
36. Address1
38. Address2
40. City
41. State
42. Zip
44. Home Phone
45. Cell Phone
47. Relationship to Subject
49. Emergency Contact Information 2:
51. First Name
52. Last Name
54. Address1
56. Address2
58. City
59. State
60. Zip
62. Home Phone
63. Cell Phone
65. Relationship to the Subject
67. Emergency Contact Information 3
69. First Name
70. Last Name
72. Address1
74. Address2
76. City
77. State
78. Zip
80. Home Phone
81. Cell Phone
83. Relationship to the Subject
85. Emergency Contact Information 4
87. First Name
88. Last Name
90. Address1
92. Address2
94. City
95. State
96. Zip
98. Home Phone
99. Cell Phone
101. Relationship to the Subject
103. Please Upload 1-3 Photos of the Subject
     Maximum size allowed: 5 MB .jpeg, .gif, .png
105. Photo 1*
106. Photo 2
107. Photo 3
109. Authorization*
     Typing my name above constitutes an affirmation under oath that I am legally responsible for the person named above for who 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.
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111. 1. Receive an email copy of this form.
112. Email address

     This field is not part of the form submission.

113. Submit

* indicates a required field