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.
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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City(*)
Please let us know your name.

State(*)
Please let us know your name.

Zip Code(*)
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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
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Are you hard of hearing or deaf
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Are you on dialysis
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Do you live alone
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Do you need assistance walking
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Do you use a wheelchair
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Are you on life support
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Are you on constant oxygen
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Do you need transportation if you needed to be evacuated
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Do you have a service animal
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Are you Ventilator dependent
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Are you visually impaired or blind
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Other Concerns
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Please update your information annually