Take Me Home Form | Summit County Prosecutor

Full Name

Name to Call Me

Date of Birth

Hair Color

Eye Color

Race

Sex

Height

Weight

Address

Address 2

City/Town

State

ZIP/Postal Code

Phone Number

Disability

Alzheimer's

Autism

Deaf

Cognitive Ability

Other

Allergies

Medications

Information an officer should know

(calming techniques/words; behaviors; language level)

Photo Upload

One file only.
100 MB limit.
Allowed types: gif jpg jpeg png.

Emergency Contact Information

Contact #1

Name

Phone

Address

Address 2

City/Town

State

ZIP/Postal Code

Contact #2

Name

Phone

Address

Address 2

City/Town

State

ZIP/Postal Code

Contact #3

Name

Phone

Address

Address 2

City/Town

State

ZIP/Postal Code

By checking this box, I confirm the following

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 Horne program. Please contact us annually to update the picture and if any information changes. ff you have additional
questions, please contact Leslie Knoblauch, Take Me Home Coordinator, at knoblauch@prosecutor.summitoh.net or (330) 643-
8741. Mail registration form and a picture of the person being enrolled to Leslie Knoblauch, Summit County Prosecutor's Office, 53
University Avenue, 6
111 Floor, Akron, OH 44308.