Special Needs Registry

Please complete this form to register special needs person with the Nether Providence Police Department.

Your Contact Information

First Name *

Last Name *

E-mail Address *

Phone Number *

Handle with Care Person

First Name *

Last Name *

Date of Birth *

Month

Day

Year

Race(s) *

Gender *

Height *

Weight *

Location

Organization / Building / etc

Street Address *

Apartment / Suite Number

City *

State *

Zip Code *

Map Marker

Hint, click the map to add or drag a GPS Marker. Zoom in for a better view.

Information

Include school/work info, car info, triggers, calming methods, service animal, etc.

Additional Notes / Condition / Consideration *

Photo

Attach a photo (jpg, jpeg, png) of the person.

Emergency Contacts

Include as much contact information as possible, e.g. name, address, phone, etc.

Emergency Contact #1 *

Additional Emergency Contacts

Agree *

I understand that submitting a false report is punishable by law.

Leave this field blank