Take Me Home Program

Family Information

The Take Me Home Program is a database facilitated by the Euclid Police Department and is only accessible to law enforcement personnel. If you have a child who is nonverbal or has developmental disabilities, or you are a caregiver to a loved one who is unable to adequately communicate information, and this person elopes from your home, officers can bring them safely home when found. The form also allows you to provide any general information you want officers to know about your loved one: how they best communicate, what makes them feel safe, what they like or dislike.

Parent or Guardian Name(Required)

First Last

Parent or Guardian Phone(Required)

Parent or Guardian Email Address(Required)

Email Address Confirm Email Address

Second Emergency Contact(Required)

First Last

Second Emergency Contact Phone(Required)

Child's Name or Adult Care Recipient's Name(Required)

First Last

Child's or Adult Care Recipiant's Birthdate(Required)

Sex/Race/Height/Weight of Child or Adult Care Recipient(Required)

Home Address: This is the home where the child or adult care recipient lives and must be returned to.(Required)

Street Address Address Line 2 City ZIP Code

Provide information you want First Responders to know about your loved one: such as diagnosis, medication, communication level, or what your loved one responds to.(Required)

Upload a Current Photo of Your Loved One

Max. file size: 128 MB.

Signature

My signature above 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.

Date