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Special Needs Notification Form
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This form has been modified since it was saved. Please review all fields before submitting.
The information you provide could be important to first responders during an emergency involving a person with special needs.
What would you like to do? Select one only.
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Information About the Person with Special Needs
Primary Telephone for Residence
Secondary Telephone for Residence
Check all that apply:
Blind or visually impaired
Cognitive impairment that can involve memory, language, thinking and judgement issues
Deaf or hard of hearing
Physically linked to equipment required to sustain his or her life
Bedridden, uses a wheelchair, or has a mobility impairment
Uses an electronic device for text communication utilizing a telephone line
General Symptoms - Check all that apply.
Medical Alert Status
Agressive in New Situations
May Hurt Themselves
Fears Flashing Lights
Fears Being Touched
Fears Loud Noises
Experiences Sensory Overload
Is there any other helpful information you can share?
Please provide your information so that we may contact you should we have further questions or follow up with submissions.
If you have questions about the Special Needs Notification Form, contact Jacksonville Public Safety 9-1-1 Center Supervisors Kristy Smith or Jeff McCallister at 910 938-7585 or by e-mail at firstname.lastname@example.org or email@example.com.
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