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127 Elm Street, Millbury, MA 01527
Telephone (508)865-3521 Fax (508)865-5164
Donald P. Desorcy, Chief of Police
“Take Me Home, Keep Me Safe Project.”
- This program is designed with safety in mind and was expanded from the “The Take Me Home Project” being used in Florida and New York. It was expanded to include individuals of all ages and disabilities and/or mental capacity.
- Essentially, the project allows an individual to be “registered” at the police department. This information is then stored at the station for reference and is only shared with Police, Fire and EMS personnel.
- For example, if your child, spouse, relative etc. were to wander off, we could run his/her name through our in-house system and be able to get emergency contact information. Their packet will also be stored in a three ring binder that will have his/her other pertinent information and an updated photograph. This is all housed at the Millbury Police Department.
- We’re hoping this project will help us locate individuals faster when/if they wander, or help us better understand and assist an individual who may have a disability or special need.
- TO REMEMBER: IT IS FAMILIES RESPONSIBILITY TO UPDATE THE FORM AND PHOTOGRAPH OF THEIR LOVED ONE.
Individual’s Name & Date of Birth:______
(First) (M.I.) (Last) (Date of Birth)
Please insert a photo of the individual here.Please provide a face shot.
Photo does not need to fit perfectly into box.
Information Specific to the Individual:
Does the individual live alone? ___yes ___no
If no who do they live with: ______Relationship:______
Method of preferred communication: ____English or Other Language: ______
If non-verbal: Picture boards:____ Written words:____ Electronic Device:______
Other: ______
If verbal, preferred words, sounds, songs, phrases, etc.: __
______
Other Relevant Medial Conditions:
No sense of danger: ___ Seizures: ___ Blind: ____ Deaf/Hearing Impaired: ____
Cognitive Impairment: ____ Developmentally Disabled: ____ Other: (specify below)
Favorite attractions/locations where the individual may be found if lost (Example: the mall, movies, library, body of water, other relative or friend address please provide address:
______
Prescription/medication needed: ______
______
Food or Medication allergies: ______
Sensory or Dietary Issues: ______
______
Behaviors or characteristics of the individual that may attract attention: ______
______
______
Individual’s favorite toys, objects, music, discussion topics: ______
______
______
How will they react to Police, EMT’s, Fire Fighters etc: ______
______
What is best way to approach them: ______
Emergency Contact Information:Name: ______Phone(s): ______
Address: ______Relationship:______
Name: ______Phone(s):______
Address: ______Relationship: ______
Name: ______Phone(s): ______
Address: ______Relationship: ______
Physician Name: ______Phone: ______
Usual Hospital Seen at: ______
______
My signature below 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, Keep Me Safe” program.
______
Signature Printed name/Date