Payson City Police Department
Special Needs Registry
Registrant Details:
Registrant Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
Photo of Registrant
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Registrant Gender
*
Please Select
Male
Female
Registrant Height
*
Registrant Weight
*
Physical Description of Registrant
Registrant Date of Birth (mm/dd/yyyy)
Special Needs (Select All that Apply)
Alzheimers/Dementia
Autism
Diabetes/Hyperglycemic
Dialysis
Epilepsy
Electricity Dependent
Hearing Impairment/Deaf
Hoarding Disorder
I/DD - Intellectual/Development Disability
Life Alert
Mental Health Disorder
Mobility Impairment: Crutches
Mobility Impairtment: Wheelchair
Mobility Impairment: Other
Obese
Oxygen Dependent
Project Life Saver
PTSD (Post Traumatic Stress Disorder)
Service Animal
Sight Impairment/Blind
Speech Impairment
Other
Describe any of the registrants medical concerns. Please list any medications currently being used.
If the registrant uses an Epi-pen, please describe the location where it is stored.
Are there any triggers which affect the registrant? (i.e. loud noises, bright lights, etc. )
Are there any calming methods used for the registrant? Describe
Does the registrant frequent/gravitate to any locations in particular? (i.e. water, playground, etc.)
Communication Methods (Check All that Apply)
Verbal
Non-Verbal
Sign Language
Written
Augmentative/Speech Assistance Device
Does the registrant own or frequently operate a motor vehicle?
Please Select
Yes
No
Safety Concerns (aggressive, suicidal, assaultive, etc.) Please give details or examples.
Please add any additional information you may think will be helpful for first responders to know regarding this registrant.
Primary Contact Information
Caregiver/Emergency Contact Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Please read and sign
The Payson City Special Needs Registry will store photographs, emergency contact information, and other personal information for special needs citizens. I understand that the information provided in this registry is made available to first responders in order to make faster identifications, reunite family members quicker and get those persons who have special needs help faster. I understand that participation in this registry is purely voluntary. I further understand that Payson City Police Department will keep information submitted in this registry secure and will only use the information when help is needed. I am the lawful and legal person eligible to submit information in this registry relative to me or the person with special needs. I hereby give my permission for the Payson City Police Department to retain and distribute the information contained in this form to other first responders for the sole purpose of identification and protection of the person identified in this form in an emergency or crisis situation.
Signature
*
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