Special Needs Registry – Livermore PD First Name* Middle Last Name* Preferred Name or what they want to be called: Date of Birth* Month Day Year Race* Hair Color* Eye Color* Scars/Birthmarks/TattoosCorrective Lenses Contacts Glasses Prescription Sunglasses Description of GlassesDriver’s License StateCA – CaliforniaAL – AlabamaAK – AlaskaAZ – ArizonaAR – ArkansasCO – ColoradoCT – ConnecticutDE – DelawareDC – District of ColumbiaFL – FloridaGA – GeorgiaHA – HawaiiID – IdahoIL – IllinoisIN – IndianaIA – IowaKS – KansasKY – KentuckyLA – LouisianaME – MaineMD – MarylandMA – MassachusettsMI – MichiganMN – MinnesotaMI – MississippiMO – MissouriMT – MontanaNE – NebraskaNV – NevadaNH – New HampshireNJ – New JerseyNM – New MexicoNY – New YorkNC – North CarolinaND – North DakotaOH – OhioOK – OklahomaOR – OregonPA – PennsylvaniaRI – Rhode IslandSC – South CarolinaSD – South DakotaTN – TennesseeTX – TexasUT – UtahVT – VermontVI – VirginiaWA – WashingtonWV – West VirginiaWI – WisconsinWY – WyomingDriver’s License Number Cell PhoneSchool Name School Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer Name Employer Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Residence/Vehicle InformationHome Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Vehicle Model Vehicle Color Vehicle License Add another Vehicle?* No Yes Vehicle Model Vehicle Color Vehicle License Parent or Guardian InformationFirst Parent/Guardian* First Name Last Name Primary Phone*Secondary PhonePlace of Employment Email Address* Second Parent/Guardian First Name Last Name Primary PhoneSecondary PhonePlace of Employment Email Address Disability/Special Need What is the registrant’s special need?*You may CHECK more than one Alzheimer’s / Dementia Autism Diabetes / Hypoglycemic Dialysis Epilepsy Electricity Dependent Hearing Impairment Intellectual Development Life Alert Mental Illness Mobility Impairment Obese Oxygen Dependent PTSD Service Animal Sight Impairment Speech Impairment Other Diabetes / Hypoglycemic Type: Mental Illness Type Mobility Impairment Type Crutches Wheelchair Other Disability/Special NeedPlease list any characteristics that are associated with this person: (Examples: sensory issues, certain behaviors, physical aggression, past dealings with police, calming strategies that work, etc.)How does this person communicate? (Words, pictures, device, etc.)Does the registrant have a Social worker / Case Worker assigned?* Yes No Name of Social Worker / Case Worker First Last PhoneEmergency Contact InformationFirst Emergency Contact* First Name Last Name Phone*Second Emergency Contact First Name Last Name PhonePlease read & enter your details below: I am the lawful and legal parent and/or guardian of the person with special needs listed in this special needs registry: Name* First Last Relationship* I understand the information provided to the Livermore Police Department is for law enforcement to have all the necessary information to better handle a situation and that information may be subject to public records laws,-F.S.S. Ch. 119- However, special needs are protected under HIPPA laws and will be redacted when necessary . Release of Information /Disclaimer I, hereby give my permission for the Livermore Police Department to retain and distribute the information contained in this registration form to other first responder personnel for the sole purpose of identification and protection of the person identified above in an emergency or crisis situation. I acknowledge 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 the authority to submit on the behalf of another. It is further understood that my completion of this form and my participation in the Special Needs Registry is completely voluntary, without guarantee, and is not intended to convey or warrant either expressly or implied any outcomes, promises or benefits from the use of this form and participation in this program. Use of the Livermore Special Needs Registry constitutes my acknowledgement and acceptance of these limitations and disclaimers. I also acknowledge that is my responsibility to keep the information on the registry up to date.I understand the release and disclaimer* Yes Please attach a recent picture of the individual*Max. file size: 128 MB.
