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2. 
4. Witten's Way Home Registry Form

   Witten’s Way Home is a voluntary registry service open to the residents of Balch Springs.  The registry is for adults and children who may have difficulty communicating due to a developmental or cognitive disability such as, but not limited to; Autism Spectrum Disorder, Schizophrenia, Dementia, Alzheimer’s, Down Syndrome or any other mental/developmental disabilities, as these individuals tend to be at risk for wandering.

   Any adult or child who may have difficulty communicating due to a developmental or cognitive disability.  The intent is to serve all members of our community who may find their communication abilities challenged or ineffective when interacting with Police.

   To register, please complete the online registration form. You can Also Download a PDF version here.

   Parents and caregivers may enroll any person, of any age, with any type of developmental or cognitive disability.  Adults with special needs may also register themselves.

6. GENERAL INFORMATION
8. First Name*
9. Last Name*
11. Nickname

    Please provide a Nickname if available.

12. Primary Language
14. Date of Birth*
    Date of Birth
15. Upload a Photo
17. Diagnosis of the Registered Person:
19. Please list any medications:
21. Does your loved one have any other medical condition(s) that we should be aware of?

    1. Yes
    2. No
22. Please explain in detail:
24. Height:

    Feet (') / Inches (")

25. Weight:
26. Gender:
28. Hair Color
29. Eye Color:
30. Race/Ethnicity
32. Do they wear Glasses?

    1. Yes
    2. No
34. What are some of their Identifying Features:

    Examples: Scars, Birthmarks, Tattoos, etc.

38. PERSONAL CHARACTERISTICS & TRAITS
40. Is there a special interest (outside of their residence) that your loved one is drawn to?

    Examples: Water, Woods, Parks, Malls, Traffic, etc.

42. If so, where was he/she found?

    Type "N/A" if answer is "No"

44. Has your loved one ever ran away or been reported as missing?

    1. Yes
    2. No
46. Is the registered person Verbal or Non-verbal?

    1. Verbal
    2. Non-Verbal
47. Please explain in detail:
49. Does the registered person fear Police or Fire-EMS personnel or emergency vehicles?

    1. Yes
    2. No
50. Please explain in detail:
52. Does your loved one have any triggers i.e. lights, sirens, loud radio noise?

    1. Yes
    2. No
53. Please explain in detail:
55. Please explain in detail any other important information that we may need to know that might assist us in not triggering a violent response from your loved one:
57. If your loved one becomes confrontational, how could Officers or Rescue Personnel calm them without your presence?
61. VEHICLE INFORMATION
63. Does your loved one still operate a vehicle?

    1. Yes
    2. No
65. If "Yes", please provide vehicle description below:
67. Make:
68. Model:
70. Color:
71. License Plate:
73. Vehicle Photo (1)
74. Vehicle Photo (2)
78. PARENT / GUARDIAN CONTACT INFORMATION
80. First / Last Name
81. Relation
83. Address
85. City
86. State
87. Zip Code
89. Home Phone
90. Cell Phone
91. Email Address
93. Development Name / Apartment Name
95. Place of Employment
97. Work Phone / Ext.
98. Work Email Address
102. (1) ADDITIONAL CONTACT
104. First / Last Name
105. Email Address
107. Address
109. City
110. State
111. Zip Code
113. Primary Number
114. Secondary Number
116. Place of Employment
117. Work Number / Ext.
121. (2) ADDITIONAL CONTACT
123. First / Last Name
124. Email Address
126. Address
128. City
129. State
130. Zip Code
132. Primary Number
133. Secondary Number
135. Place of Employment
136. Work Number / Ext.
140. (3) ADDITIONAL CONTACT
142. First / Last Name
143. Email Address
145. Address
147. City
148. State
149. Zip Code
151. Primary Number
152. Secondary Number
154. Place of Employment
155. Work Number / Ext.
157. 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.

     1. I agree.
159. Electronic Signature
Leave This Blank:


161. 1. Receive an email copy of this form.
162. Email address

     This field is not part of the form submission.

163. Submit

* indicates a required field