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Take Me Home Program

  1. TAKE ME HOME PROGRAM

  2. PERSONAL INFORMATION

  3. (Nombre)

  4. (Llámame)

  5. (Direccion)

  6. (Cuidad)

  7. (Codigo Postal)

  8. (Telefono)

  9. (fecha de nacimiento)

  10. (Raza)

  11. (Peso)

  12. (Color de pelo)

  13. (Color de los ojos)

  14. (Talla)

  15. (Peso)

  16. DISABILITY INFORMATION (DISCAPACIDAD):

  17. Disability (Discapacidad):*

  18. Organization (Organización):*

  19. EMERGENCY CONTACT INFORMATION (Use NA if Not Applicable)

    (NA si no corresponde)

  20. (Nombre)

  21. (Telefono)

  22. (Direccion)

  23. (Relación)

  24. (Nombre)

  25. (Telefono)

  26. (Direccion)

  27. (Relación)

  28. (Nombre)

  29. (Telefono)

  30. (Direccion)

  31. (Relación)

  32. (Nombre)

  33. (Telefono)

  34. (Direccion)

  35. (Relación)

  36. INFORMATION SPECIFIC TO THE INDIVIDUAL (Use NA if not applicable)

    (Información específica a la persona si es aplicable - NA si no corresponde)

  37. The submission of this form 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.

    (Mi firma a continuación constituye una afirmación bajo juramento de que soy legalmente responsable de la persona mencionada anteriormente por la que proporcioné información y que consiento en que esta información se comparta entre el personal del orden público para inscribirse en el programa "Take Me Home”.)

  38. I give my permission as the Parent/Guardian of the above-named individual to the Plano Police Department to retain and distribute this information to first responding personnel (Fire, EMS, and Police) for the sole purpose of identification and assistance to the above-named person with special needs. The completion of this form shall not create a right to services, nor shall it create a special relationship between the parties. The Department will make a reasonable effort to relay provided information to responding personnel. The Department, however, shall not be held responsible for failure to do so and no guarantee is made, expressed, or implied that said information will be relayed.

  39. By clicking the following statement, I acknowledge that I have read the Release/Disclaimer.*

  40. NOTICE:

    IT IS THE RESPONSIBILITY OF THE PARENT/GUARDIAN/CAREGIVER TO NOTIFY THE PLANO POLICE DEPARTMENT OF ANY CHANGE IN STATUS. ALERTS ARE AUTOMATICALLY REMOVED FROM THE SYSTEM 24 MONTHS FROM THE DATE OF SUBMISSION. ALERTS MUST BE RENEWED EVERY 24 MONTHS.

  41. Leave This Blank:

  42. This field is not part of the form submission.