Special Needs Registry

Please complete this form to register a person with special needs with the Upper Merion Township Police Department.

By completing this form, I acknowledge that the information provided herein is accurate and was submitted voluntarily for the sole purpose of assisting Upper Merion Police and Emergency Services in more effectively responding to a potential emergency in or near my household. This information will be used at the discretion of Emergency Services and may not be disseminated in certain circumstances prior to arrival. Form submissions can be withdrawn at any time.

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

Get Address from Map Marker

Organization / Building / etc

Street Address *

Apartment / Suite Number

City *

State *

Zip Code *

Map Marker

Use Location Address Use My Current Location

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

Information

Please include the following:

How does this individual respond to stress? e.g. shut down, kick/hit
Best way to approach this individual or reduce their stress?
Anything else that could be helpful to First Reponders?

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