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] 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

First Name

Last Name

Age

Date of Birth

Month

Day

Year

Email Address

Home Phone

Cell Phone

Address

Street Address Address Line 2 City State ZIP Code

Gender

Male

Female

Special Needs

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

First Name

Last Name

Age

Date of Birth

Month

Day

Year

Relationship to Client

Email Address

Home Phone

Cell Phone

Address

Street Address Address Line 2 City State ZIP Code

Contact 2

First Name

Last Name

Age

Date of Birth

Month

Day

Year

Relationship to Client

Email Address

Home Phone

Cell Phone

Address

Street Address Address Line 2 City State ZIP Code

Contact 3

First Name

Last Name

Age

Date of Birth

Month

Day

Year

Relationship to Client

Email Address

Home Phone

Cell Phone

Address

Street Address Address Line 2 City State ZIP Code

Caregiver

First Name

Last Name

Age

Date of Birth

Month

Day

Year

Relationship to Client

Email Address

Home Phone

Cell Phone

Address

Street Address Address Line 2 City State ZIP Code

Section 3: Vehicle Information

Vehicle 1

Year

Make

Model

Type

Car, Truck, SUV, Motorcycle, Moped

Color(s)

Noticable Damage

License Plate

License Plate State

Additional Information

Vehicle 2

Year

Make

Model

Type

Car, Truck, SUV, Motorcycle, Moped

Color(s)

Noticeable Damage

License Plate

License Plate State

Additional Information

Vehicle 3

Year

Make

Model

Type

Car, Truck, SUV, Motorcycle, Moped

Color(s)

Noticeable Damage

License Plate

License Plate State

Additional Information

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.