Special Needs Emergency Contact Form

We have implemented this program to help our dispatchers to relay the most accurate and helpful information to our responders. The information you give us in this form will be associated with the address you also give in the form, therefore any time there is a call for responders at your address anyone responding will be aware of your loved ones’ special needs. These forms will need to be updated yearly to make sure we maintain accurate information to make sure the best care is given to your loved ones

Step 1 of 2
Click or drag a file to this area to upload.
Attache a photo of the Child/Adult with Special Needs
ATT, Verizon, T-Mobile, etc.
If Non-Verbal:Sign Language, Picture Board, Written Word, Etc
Jewelry/Medic Alert, clothing tags, ID card, tracking monitor, etc
Including Dosage
If Any
Including approach and de-esclation techniques