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Special Needs Registry Form

Everybody Has Needs - Do the Right People Know What Yours Are? If you or someone in your household has a disability or a special medical need, the people whose job it is to respond when you call for help in an emergency need to know. Whether it affects your entire community, your street or just your home, seconds can make a life-or-death difference. Having specific details about your special situation will significantly help us help you.

Special Needs Registry Form (PDF)

Special Needs Registry Form (DOC Version)

Date I'm completing form(*)

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Filling out this form is strictly voluntary and the data will be kept strictly confidential. It will be available only to local emergency assistance officials. Please print clearly and provide all information.

First Name(*)

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Last Name(*)

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Your Language (if not English)

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In Total, how many people live in your household?(*)

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Your Phone #(*)

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Date of Birth(*)

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Street Address(*)

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Apartment No.

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Type of Residence(*)

Assisted Living FacilityHouseSenior Housing Complex/Facility Invalid Input

City(*)

Please let us know your name.

State(*)

Please let us know your name.

Zip Code(*)

Please let us know your name.

In an emergency, please contact:

First Name(*)

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Last Name(*)

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Their Relationship To You(*)

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Their Primary Phone #(*)

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Their Secondary Phone #

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Circle all that apply

Are you confined to your bed

YesNo Invalid Input

Are you hard of hearing or deaf

YesNo Invalid Input

Are you on dialysis

YesNo Invalid Input

Do you live alone

YesNo Invalid Input

Do you need assistance walking

YesNo Invalid Input

Do you use a wheelchair

YesNo Invalid Input

Are you on life support

YesNo Invalid Input

Are you on constant oxygen

YesNo Invalid Input

Do you have your own transportation?

YesNo Invalid Input

Do you have a service animal

YesNo Invalid Input

Are you Ventilator dependent

YesNo Invalid Input

Are you visually impaired or blind

YesNo Invalid Input

Do you have Alzheimer's / Dementia

yesno Invalid Input

Other Concerns

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Please update your information annually

Submit

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