Find My Home-Application

form.antibot { display: none !important; } You must have JavaScript enabled to use this form.

APPLICANT INFORMATION (CAREGIVER)

Name *

Address *

City *

State *

Zip *

Phone Number *

Email Address *

Relation to Enrollee *

FIND MY HOME ENROLLEE INFORMATION

Enrollee Name *

Disability *

Alzheimer's

Autism Spectrum

Other

If "Other" Please Explain

Enrollee Nickname *

Sex *

Hair Color *

Eye Color *

Date of Birth *

Ethnicity *

Height *

Approximate Weight *

Enrollee Address *

City *

State *

Zip *

Phone Number *

Vehicle Make *

Vehicle Model *

Vehicle Year *

Vehicle Color *

Vehicle License Plate Number *

Current Photograph of Enrollee *

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png.

Additional Medical Conditions or Necessary Medication(s) the individual is taking

Favorite Places or attractions (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):

Any additional information that would be helpful to first responders? For example, the individual might not like to be touched.

Does the individual fear Police and or Fire/EMS? *

Yes

Are lights associated with police and fire vehicles an emotional trigger? *

Yes