Special Needs Registry (Cranford PD) Cranford Police DepartmentSPECIAL NEEDS REGISTRY The Cranford Police Department Special Needs Registry is a voluntary service open to all citizens with disabilities who reside, attend school, or are employed in Cranford. The registry was created to help police officers and other emergency personnel, better assist residents with special needs in the event of an emergency by providing those first responders with vital information regarding a registrant’s disability, emergency contact information, physical description, and current photograph.First Name Last Name Middle Initial Nickname (If Any) Home Address City, State and Zip Driver's License State Driver's License Number Email Address Home Phone #Cell Phone #Person Filling Out This Form (If Different from Above)First Name Last Name Relationship to Registrant Registered VehiclesDoes the registrant own or operate a motor vehicle? Yes No Registration State License Plate # Make Model Color Registration State License Plate # Make Model Color Does the registrant own or operate a bicycle? Yes No Make Model Speeds Color Registrant IdentifiersDate of Birth Gender Male Female Race Height (ft.) (Inches) Weight (in pounds) Build(Required) Hair Color Eye Color Corrective Lenses Contact Lenses Eye Glasses Prescription Sunglasses Scars/Piercings/Marks/Tattoos (location)CommunicationMethod of Communication Augmentative/Speech Assistance Device Non-Verbal Verbal Sign Language Written What type of Augmentative/Speech Assistance Device does the registrant use?What type of sign language does the registrant use?What language(s) does the registrant speak or understand?Registrant School / Employment InformationDoes the registrant attend school or are they employed? Yes No Name of School / Employer School / Employer Address School / Employer City, State and Zip School / Employer Phone #Contact (Additional School / Employer)Name of School / Employer: School / Employer Address School / Employer City, State and Zip School / Employer Phone #Contact Special NeedsWhat is the registrant’s special need? (Select all that apply) Alzheimers / Dementia Autism Diabetes / Hyperglycemic Dialysis Epilepsy Electricity Dependent Hard of Hearing / Deaf, or other Hearing Impairment I/DD – Intellectual / Developmental Disability Life Alert Mental Illness Mobility Impairment: Wheelchair Mobility Impairment: Other Oxygen Dependent Project Life Alert PTSD (Post-Traumatic Stress Disorder) Service Animal Sight Impairment / Blind Speech Impairment Other Diabetes / Hyperglycemic Type Other Mobility Impairment Other Special Need Describe any of the registrant’s life threatening medical concerns: (eg. food or medicine allergies, seizures, etc.)Does the registrant use an Epi-pen? Yes No (If yes, please give location where it is stored) Any Triggers which affect the registrant? (i.e., Loud Noises, Brigh tLights)Any Calming Methods used for the registrant?Does the registrant frequent / gravitate to water, playgrounds, etc.? Yes No (If yes, give locations) What products / equipment and with which vendor does the registrant have from Life Alert / Project Life Saver? (eg. pendant, wristband, mobile app, push HELP button, etc.)Does the registrant have a Social Worker / Case Worker assigned? Yes No Name of Social Worker / Case Worker Phone #Does the registrant have a service animal? Yes No If yes, give the type/description, name and what the service animal assists withAny other information that may be important?Emergency Contact InformationFirst Name Last Name Address City, State and Zip Home Phone #Cell Phone #Relationship to the registrant Is this person the Legal Guardian of the registrant? Yes No Additional Emergency Contact InformationFirst Name Last Name Address City, State and Zip Home Phone #Cell Phone #Relationship to the registrant REGISTRANT PICTURES Drop files here or Select files Max. file size: 128 MB. please attach as many pictures of the registrant that you feel are necessary.Acknowledgement I acknowledge that by checking the box below that the information being provided is truthful, current and valid and that I 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 Cranford 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, 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 Cranford 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 Cranford Police Department Special Needs Registry constitutes acknowledgment and acceptance of these limitations and disclaimers.I understand the above disclaimer(Required) Yes No Signature of the person filling out this form)Date MM slash DD slash YYYY Name of person filling out this form
