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Applicant Information
First Name*
Last Name*
Address1*
Address2
City*
State*
Zip*
Phone Number*
Email address*
Find My Home Enrollee Information
First Name*
Last Name*
Nickname
Sex*
Hair Color*
Eye Color*
Date of Birth
Ethnicity*
Height*
Approximate Weight*
Disability*
1. Alzheimer's
2. Autism Spectrum Disorder
3. Other
If "Other", Please Explain:
Additional Medical Conditions or Necessary Medication(s) the Individual is Taking:
Home Address 1*
Home Address 2
City*
State*
Zip*
Phone Number*
Email Address
Vehicle License Plate Number
Vehicle Make
Vehicle Model
Vehicle Year
Vehicle Color
Current Photograph No. 1*
Current Photograph No. 2
Current Photograph No. 3
Favorite place or attraction where he/she may be found (i.e. previous addresses, specific parks, stores, restaurants, etc.):
Behaviors or characteristics of the individual that may attract attention:
Individual's favorite objects or discussion topics, as well as any specific likes or dislikes:
Method of preferred communication (if nonverbal - sign language, picture boards, written words, etc.):
What unique items might the person be carrying? Examples include specific jewelry, ID card, or medical alert bracelets.
Please list any likes/dislikes when it comes to approaching the individual (including de-escalation techniques):
Does the individual fear police and or fire/EMS?
1. Yes
2. No
Are lights associated with police and fire vehicles an emotional trigger?
1. Yes
2. No
Any additional information that would be helpful to first responders? For example, the individual might not like to be touched.
Emergency Contact Information
Emergency Contact No. 1
First Name*
Last Name*
Address1*
Address2
City*
State*
Zip*
Best Phone Number to Reach Them*
Relationship to Enrollee*
Emergency Contact No. 2
First Name
Last Name
Address1
Address2
City
State
Zip
Best Phone Number to Reach Them
Relationship to Enrollee
Emergency Contact No. 3
First Name
Last Name
Address1
Address2
City
State
Zip
Best Phone Number to Reach Them
Relationship to Enrollee