Santaquin/Genola Police Department Special Needs Registry

Special Needs Registry

Purpose: To compile and maintain a list of residents who have a mental or intellectual disability that puts them at risk for becoming lost, confused, wander off, or otherwise involved in an emergency situation. This information can be critical for our officers when helping individuals with disabilities.

Examples: Residents diagnosed with Alzheimer's, Dementia, Autism Spectrum Disorder,
Down Syndrome, etc.

***Note: The Special Needs Registry form will be sent to the police department as an encrypted email that will protect medical information required on this form.

Person being placed on the Special Needs Registry:
Name*

First and Middle NameLast Name
Nick Name(s) / Preferred Name
Address*

Street Address

Apartment Number if applicable

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Social Security Number
Driver License Number (if applicable)
Race / Ethnicity*

American Indian or Alaska NativeAsianBlack or African AmericanCaucasianHispanic or LatinoNative Hawaiian or other Pacific Islander
Gender*

MaleFemale
Height*
Weight*
Eye Color*
Glasses*

YesNo
Hair Color or Bald*
Hairstyle (buzzed, short, shoulder length, long past shoulders, etc.)*
Identifying Features (scars, marks, tattoos, etc.)
Special Needs / Disabilities / Medical Condition(s)
Current Prescription Medication(s)
Allergies
Communication*

VerbalNon-VerbalSign LanguageOther (Explain below)
Explanation for other communication
Sensory Issues (please explain)
Fears or triggers that may upset individual (please give details or examples)
Calming methods (favorite topics, interest, music, etc.)
Places of interest or places the person has wandered before (rivers, parks, etc.)
Safety Concerns (aggressive, suicidal, assaultive, etc.) (Please give details or examples)
Other pertinent information
Upload recent photo*

Cancelof
Caregiver/Emergency Contact Information:
Name*

First NameLast Name
Relationship to registrant (person being placed on Special Needs Registry)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Alternate Caregiver/Emergency Contact information:
Name*

First NameLast Name
Relationship to registrant (person being placed on Special Needs Registry)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please read and sign:

As part of the Special Needs Registry program, we receive and store photographs, emergency contact information, and other personal information for special needs citizens. This information is made readily available to Santaquin Police Department Officers. It is stored and accessed in such a manner that first responders may make faster identifications, reunite family members quicker, and get those persons the help they need faster.

Participation in this program is purely voluntary. The information collected is kept secure and is only used to assist those persons in need of our help. The information collected under this program is CONFIDENTIAL and will need to be updated yearly for children and as needed for adults.

I understand the above statements and verify that I am the lawful and legal parent and/or guardian of the person with special needs listed above. I hereby give my permission for the Santaquin Police Department to retain and distribute the information contained in this 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.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: