Bayonne Police Department - Special Needs Registry

  • SPECIAL NEEDS REGISTRY

    The Bayonne Police Department Special Needs Registry is a voluntary service open to all citizens with special needs who reside, attend school, or are employed in Bayonne. The registry was created to help police officers and other emergency personnel, better assist residents with special needs in the event of an emergency by providing those first responders with vital information regarding a registrant’s special need, emergency contact information, physical description, and current photograph.

  • Registrant Information

  • Does the registrant have a valid driver’s license?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you filling out this form for yourself or someone else?*

  • Person Filling Out This Form

    If Different from Above

  • Registered Vehicles

  • Does the registrant own or operate a motor vehicle?*

  • Vehicle I

  • Vehicle II

  • Does the registrant own or operate a bicycle?*

  • Registrant Identifiers

  • Date of Birth*
     - -
  • Gender*
  • Race*
  • Ethnicity*
  • Corrective Lenses

  • Communication

  • Method of Communication*

  • Registrant School/Employment Information

  • Does the registrant attend school or are they employed?*
  • Format: (000) 000-0000.

  • Additional School / Employer

  • Format: (000) 000-0000.

  • Special Needs

  • What is the registrant’s special need?*
  • Does the registrant use an Epi-pen?*
  • Does the registrant frequent / gravitate to water, playgrounds, etc.?*
  • Does the registrant have a Social Worker / Case Worker assigned?*
  • Format: (000) 000-0000.
  • Does the registrant have a service animal?*

  • Emergency Contacts and Registrant Pictures

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is this person the Legal Guardian of the registrant?*

  • Additional Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Registrant Pictures

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Acknowledgement & Submission

  • I acknowledge that by checking the box below that 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 authority to submit it on behalf of another. I further understand that by enrolling myself or someone else in the Bayonne Police Department Special Needs Registry that the personal information entered may be used by emergency personnel, including, but not limited to, law enforcement officers, emergency medical services, and fire department personnel in the event of a personal emergency or other emergency situation. I also acknowledge
    that it will be my responsibility to keep the information on the registry up-to-date.

    It is further understood that completion of this form and participation in the Bayonne Police Department Special Needs Registry is voluntary and cannot guarantee and is not intended to convey and warrant, either express or implied, as to outcomes, promises, or benefits from the use of this form and participation in this program. Use of the Bayonne Police Department Special Needs Registry constitutes acknowledgment and acceptance of these limitations and disclaimers.

  • I understand the above disclaimer*
  • Date*
     - -
  •  
  • Should be Empty: