Section 1 of 1 in this document

BRISTOL POLICE DEPARTMENT

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 alyshapirog@bristolct.gov

Sex

Race

Address Autocomplete

Address or Location

Height

Feet

Inches

Weight

Hair Color

Eye Color

Nickname

Scars, markings, tattoo’s, piercings

Address Autocomplete

Address or Location

Phone Number

Home

Cell

Work

Address Autocomplete

Address or Location

Phone Number

Home

Cell

Work

Address Autocomplete

Address or Location

Phone Number

Home

Cell

Work

Address Autocomplete

Address or Location

Phone Number

Home

Cell

Work

Phone Number

Communicates Verbally:

Yes

Method of Communication:

Sign Language

Picture Board

Written Words

Please indicate which statements are true of the individual:

Lives Alone

May Become Disoriented

May roam away from home and would be considered at risk.

May be unable to communicate own name, address, etc. if put under stress.

Likely unable to cope with three or more days of power outage at home.

Unable to evacuate from home and summons proper assistance if required.

Possesses a medical condition causing a lack of necessary communication with first responders, or a medical condition that may mimic hostility, intoxication, etc.

Please explain statements checked above if necessary:

Sensory, medical, or dietary issues and recommendations:

Inclination for wandering and any atypical behaviors or characteristics which may attract attention:

Favorite attractions and/ or locations where individual may be found:

Likes, dislikes, approach, and de-escalation techniques:

Any other pertinent information:

Recent Photo(s) of Individual

Date

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

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

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BRISTOL POLICE DEPARTMENT

Special Needs Registry Application

Name of Individual

Date of Birth

Address Autocomplete

Height

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

Date

Name of person Authorized to provide information and waiver

Signature