Person With Special Needs Emergency Information Form

There are a number of instances where the police provide assistance and emergency services to assist people with special needs. In some of these circumstances, while time is of the essence, the assistance of the police and other emergency services personnel is delayed by the need to gather information about the person with special needs.

It is for this reason that the Milford Police Department seeks to gather and maintain this important information prior to the immediacy when an event is unfolding.

Please fill out the information below as completely as possible, and please provide any additional information that you think might be helpful to us in helping you. If an item does not apply to your circumstances, please leave it blank. If there is information that you feel we should know, but we have not asked, please provide it within the "Additional comments" section of the questionnaire.

Please attach a clear and distinguishable current photograph depicting only the person with special needs.

Upon receipt of your completed questionnaire, we will contact you to verify the content of the information provided and to solicit any additional information that may be helpful to us in helping you and your loved one should the need arise.

All information will be maintained as confidential.

If you have any questions regarding this special needs program, please call 508-473-1113 and speak with the Administrative Sergeant at extension 652 or the Chief of Police at extension 611.

Person with Special Needs - Name:
Address:
Local Telephone:
Mobile Phone:
Date of Birth:
Gender:	Select gender Female Male
Race/ethnicity:
Height:
Weight:
Hair color:
Eye color:
Allergies:
Fears:
Likes and dislikes:
Condition:
Socio-symptomology:
Emergency family contact- Name:
Emergency family telephone:
Emergency medical name (i.e. doctor):
Emergency medical telephone:
Parent/guardian name:
Parent/guardian address:
Parent/guardian telephone:
Parent/guardian cell phone:
Medical facility name:
facility address:
facility telephone:
Other emergency contact:
Other emergency telephone number:
Additional comments:
Please attach recent photo: