Handle with Care Application

Please complete this form for each member of your household that requires any special accommodations.

If you'd prefer to print this form and return it to the Goochland County Sheriff's Office by email at [email protected]andva.us or by mail at the address below, please tap here to download an uncompleted copy to your device

Handle with Care
c/o GCSO
P.O. Box 29 Goochland, VA 23063

Section 1: Client Information

Date of Birth
Address
Gender
Please list any other Physical, Psychological, or Diagnosed Behavioral special needs which shall serve as a reminder to the first responders that needed special consideration or attention may be needed or given to the individual involved in a call for service. (Examples Autism, Dementia, Down Syndrome, Hearing Impaired, Immobility, Speech or language impaired, Etc.)

Section 2: Emergency Contact Information

Contact 1

Date of Birth
Address

Contact 2

Date of Birth
Address

Contact 3

Date of Birth
Address

Caregiver

Date of Birth
Address

Section 3: Vehicle Information

Vehicle 1

Car, Truck, SUV, Motorcycle, Moped

Vehicle 2

Car, Truck, SUV, Motorcycle, Moped

Vehicle 3

Car, Truck, SUV, Motorcycle, Moped

Please allow three business days for contact by Sheriff's Office personnel. All information received on this form will be kept private and not for public use. If you have any questions, please call the Sheriff's Office at 804-556-5349.