ITDept@bristolct.gov
111 North Main Street, Bristol, CT, 06010, US
860-584-6100
Name of Individual
Date of Birth
Address Autocomplete
Height
Parent or Guardian Name (1)
Phone Number
Parent or Guardian Name (2)
Additional Caregiver Name
Emergency Contact
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
Date
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.
Signature