Special Needs Registry

Please complete this form to register special needs person with the Highspire Borough Police Department.

Your Contact Information

First Name *

Last Name *

E-mail Address *

Phone Number *

Handle with Care Person

First Name *

Last Name *

Date of Birth *

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

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Year Year19081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023

Race(s) *

Gender * - Select -MaleFemale

Height *

Weight *

Location

Address: Get Address from Map Marker

Map MarkerUse Location Address | Use My Current Location

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

Organization / Building / etc

Street Address *

Apartment / Suite Number

City *

State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code *

Information

Include school/work info, car info, triggers, calming methods, service animal, etc.

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

Submit