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Special Needs Registry
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
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Assisted Living Facility
House
Senior Housing Complex/Facility
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City
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Please let us know your name.
State
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Please let us know your name.
Zip Code
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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
Yes
No
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Are you hard of hearing or deaf
Yes
No
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Are you on dialysis
Yes
No
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Do you live alone
Yes
No
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Do you need assistance walking
Yes
No
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Do you use a wheelchair
Yes
No
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Are you on life support
Yes
No
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Are you on constant oxygen
Yes
No
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Do you have your own transportation?
Yes
No
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Do you have a service animal
Yes
No
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Are you Ventilator dependent
Yes
No
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Are you visually impaired or blind
Yes
No
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Do you have Alzheimer's / Dementia
yes
no
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Other Concerns
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Please update your information annually
Submit
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