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City of Bristol CT

111 North Main Street, Bristol, CT, 06010, US



Special Needs Registry Application

Please fill out the following pages as completely and accurately as possible. Our Goal is to supply responding Police, Fire, and EMS personnel with current and accurate information in order to deal with your emergency in a caring and professional manner. Providing information is voluntary.
For any questions, please contact Officer Alysha Pirog at (860) 584-3011 or

Name of Individual

Date of Birth

Address Autocomplete


    Parent or Guardian Name (1)

    Address Autocomplete

      Phone Number

      Parent or Guardian Name (2)

      Address Autocomplete

        Phone Number

        Additional Caregiver Name

        Address Autocomplete

          Phone Number

          Emergency Contact

          Address Autocomplete

            Phone Number

            Medical Care Provider's Name

            Communicates Verbally:

            Method of Communication:

            In order to properly classify the individual's special needs, please rate their ability to perform the following tasks, leave non‐applicable questions blank. Please check all medical conditions which they should be considered to possess:

            Please indicate which statements are true of the individual:

            Recent Photo(s) of Individual

            Click Here to Upload


            Date Picker

            Name of person Authorized to provide information and waiver

            By completing this form I understand I am responsible to notify the Bristol Police Department ANNUALLY of any changes with regard to the above information.


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