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)
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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.
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Please let us know your name.

Please let us know your name.

Please let us know your name.


In an emergency, please contact:
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Circle all that apply
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Please update your information annually