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Special Needs Registry Form

Franklin Police Department, Franklin, WI

The City of Franklin Police Department recognizes that some members of our community may have special needs, or may react differently when coming into contact with police officers or firefighters during an emergency situation. With this in mind, we’ve created a Special Needs Registry.

The Special Needs Registry is available for all residents requiring special needs resulting from a physical, emotional, or medical condition (i.e. dementia, autism, etc.). Information provided is maintained in a confidential database which will assist emergency responders in providing a more informed response to those with special needs during an emergency.  If you are interested in participating in the Special Needs Registry, please fill out and submit the form below.

If you wish to send a photo of the Special Needs Person, please send the photo separately to specialneedsregistry@franklinwi.gov.
 


 

SPECIAL NEEDS PERSON

Name (Last, First, M.I.):        Male /  Female    DOB:  

Address:     Nickname: 

Home Phone:     Cell Phone:     Email: 

PERSONAL HEALTH HISTORY

Height:      Weight:       Eye Color:       Hair Color:  

Medical Alert Worn:   Yes    No  /  If yes, what type and where worn?  

Scars, Marks, Tattoos:  

List any medical conditions that the Special Needs Person has been diagnosed with or is being treated for:

INFORMATION SPECIFIC TO THE SPECIAL NEEDS PERSON

Does the individual live alone?   Yes   No  /  Is he/she likely to wander off?   Yes   No

Is the Special Needs Person hearing impaired?   Yes   No 

Is the Special Needs Person visually impaired?   Yes   No

Favorite attractions or locations where the individual may be found?

Location of bedroom or likely place to find the individual in the residence at night?

Behaviors or characteristics of the individual that may attract the attention of responders?

Actions that may trigger outbursts or irrational behavior of the individual?

Favorite toys, objects, discussion topics, likes or dislikes of the individual?

Is the Special Needs Person   Verbal    Non-Verbal

Prefers other means of communication (see below for specifics):

Preferred Method of Communication?  (If non-verbal; sign language, picture boards, written words, etc.)

Is there any other information that may be helpful to responders when coming in contact with this Special Needs Person?

EMERGENCY CONTACT INFORMATION

Emergency Contact #1:

Name:       Relationship:  

Address:  

Home Phone:      Cell Phone:       Other Phone: 

Emergency Contact #2:

Name:       Relationship:  

Address:  

Home Phone:       Cell Phone:       Other Phone:  

Emergency Contact #3:

Name:       Relationship:  

Address:  

Home Phone:       Cell Phone:       Other Phone:  


IMPORTANT: please review the following before signing and/or submitting this form: Responding to this form is strictly voluntary. The information on this form will be added to the Franklin Police Department’s record management system, and may be distributed to emergency responders in order to better care for you or your family members. The City respects your right to confidentiality and will strive to ensure that your personal information remains confidential. However, by definition of this form, once submitted, is a public record, and may be subject to disclosure under WI Stat.§19.35, except as otherwise exempted by law. The City does not collect or maintain information about you that is not essential for your safety and well-being. By completing this Special Needs Registry form, I acknowledge that the information provided herein is accurate, and was submitted voluntarily for the sole purpose of assisting Police, Fire and Emergency Response Departments in more effectively responding to a potential emergency in or near my residence. I, therefore, authorize the use of this information for those purposes.


Person Completing Form:  / Relationship to Registree:  / Date: