Special Needs Person Online Registration Special Needs Person AdultJuvenile Last Name First Name Middle Name Nickname Birth Date Physical Description Sex ---MaleFemale Race Complexion ---LightMediumDark Height Weight Build ---SlenderMediumHeavyMuscular Eye color Hair color Hair style Facial hair Tatoos/Scars/Birthmarks (and location) Other physical features Please provide a photograph of the special needs person. Special Needs Information Please fill out all information that applies. Primary Diagnosis Secondary Diagnosis Documented attraction to water? YesNo Can he/she swim? YesNo Sensitivity to lights/sounds? YesNo Please describe sensitivities How does he/she communicate? Triggers Calming techniques Additional medical conditions Information that would help officers better interact with individual Contact Information Address Phone Number School (if applicable) School phone/best contact Caregiver/Emergency Contact Last Name First Name Middle Name Address Phone Number Email Acknowledgement I acknowledge that by checking the box below that the information being provided is truthful, current and valid and that am authorized to submit it on my own behalf or as the legal guardian with authority to submit it on behalf of another. I further understand that by enrolling myself or someone else in the Calhoun Police Department “Special Needs Registry” that the personal information entered may be used by emergency personnel, including, but not limited to, law enforcement officers, emergency medical services (first aid/paramedics), and fire department personnel in the event of a personal emergency or other emergency situation. I also acknowledge that it will be my responsibility to keep the information on the registry up to date. It is further understood that completion of this form and participation in the Calhoun Police Department “Special Needs Registry” is voluntary and cannot guarantee and is not intended to convey and warrant, either express or implied, as to outcomes, promises, or benefits from the use of this form and participation in this program. Use of the Calhoun Police Department “Special Needs Registry” constitutes acknowledgement and acceptance of these limitations and disclaimers. I understand the above disclaimer (required) Name of person submitting this form Date
