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Bring Me Home Program Registration Form

  1. REGISTRANT BASIC INFORMATION
  2. Is the registrant approachable? *
  3. Is the registrant employed?
  4. Is the registrant in school?
  5. REGISTRANT PHYSICAL DESCRIPTION
  6. Does the registrant wear glasses?
  7. Please list any identifying marks, scars, or tattoos. Please also list any medical allergies, possible medication side effects, or any other medical conditions that law enforcement should be aware of.

  8. EMERGENCY CONTACT
  9. REGISTRANT BEHAVORIAL DETAILS
  10. Is the registrant non-verbal? *
  11. Initial Entry or Update? *
  12. Enrollment Signature
  13. Are you legally responsible for the person named above as registrant (i.e., parent of minor child, court appointed guardian). The Sheriff's Office may require proof of legal responsibility at any time to register or continue participation in the program.*
  14. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  15. Leave This Blank:

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