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Specific Response Registry Form

  1. Select One:

  2. REGISTRANT INFORMATION

    Please complete this section for the subject of this registry. Note: A separate registration form must be submitted for each person to be registered.

  3. Sex:

  4. i.e. tattoo on left wrist of a flower, birth mark on right shoulder, etc.

  5. Are there any animals in the home?

  6. Is there a service animal in your home?

  7. MEDICAL INFORMATION / IMPAIRMENTS

    In this next section please describe to the best of your ability each condition to help us better understand the unique needs of the registrant.

  8. Check all that apply:

  9. Mobility:

  10. Hearing:

  11. Speech:

  12. Vision:

  13. Do they require any medication for above listed conditions?

  14. Does the registrant tend to wander off?

  15. i.e. garage code, lock box location and code, hidden key, etc.

  16. In the event the registrant wanders off or goes missing a recent photograph can be an extremely useful tool to assist Law Enforcement and other first responders in locating them.

  17. Caregiver and Emergency Contact Information

  18. First and Last Name : XXX-XXX-XXXX

  19. IMPORTANT: Please review the following before submitting this form:*

    Responding to this form is strictly voluntary. By completing and submitting this form, I acknowledge that the information provided herein is accurate and was submitted voluntarily. I understand that the information on this form will be added to the Town’s dispatch systems and may be distributed to emergency responders in order to better care for me and my family members. I understand that all information provided may be a public record subject to disclosure to the public. I also understand and acknowledge that the Town’s dispatch center is not a “covered entity” under the Health Insurance Portability and Accountability Act (“HIPPA”) and I have no rights with respect to the possession, use or disclosure of this information by the Town’s dispatch center under HIPPA. I further understand that providing this information does not entitle me or anyone in my household to preferential treatment, including a more timely response by emergency personnel. I recognize that in the event of an emergency I must dial 911. I acknowledge that I am responsible for the accuracy of the information provided and for updating the information when it changes or annually. I further understand that this information may be removed from the database and destroyed after one year until I resubmit the information.

  20. Leave This Blank:

  21. This field is not part of the form submission.