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2. Clark Police Department-Special Needs Registry

   The Clark Police Department Special Needs Registry is a voluntary service open to all citizens with disabilities or specialized medical needs or equipment who reside, attend school, or are employed in Clark. The registry was created to help police officers and other emergency personnel, better assist residents with special needs in the event of an emergency by providing those first responders with vital information regarding a registrant's disability, emergency contact information, physical description, and current photograph.

4. Tell Us About the REGISTRANT with Special Needs
6. Registration Status*
   -- Select One --This is a First-Time RegistrationThis is a Revised/Updated Registration
8. First Name of REGISTRANT*
9. Last Name of REGISTRANT*
11. Address*
13. City*
14. State*
15. Zip Code*
17. Phone Number*
18. Cell Phone Number
20. Email Address
22. Date of Birth*
23. Sex
    -- Select One --FemaleMale
24. Optional: Gender
    -- Select One --Non-BinaryTransgenderIntersexPrefer to Self-Describe
25. Optional: Self-Describe
27. Race
28. Weight (in pounds)*
29. Height*
30. Hair Color*
32. Eye Color*
33. Corrective Lenses*
    -- Select One --NOContact LensesEye GlassesPrescription Sunglasses
35. Scars/Piercings/Marks/Tattoos(location)*
37. Communication
39. Method of Communication*
    -- Select One --Augmentative/Speech Assistance DeviceNon-VerbalVerbalSign LanguageWritten
40. Comments on Language
42. Any Triggers? (loud noises, bright lights, etc)
43. Any Calming Methods used?
45. Does Registrant Frequent a Location? (If so, please explain where)
47. Special Needs
49. What is the registrant's special need? *

    1. Alzheimers/Dementia
    2. Autism
    3. Diabetes/Hyperglycemic
    4. Dialysis
    5. Epilepsy
    6. Electricity Dependent
    7. Hard of Hearing/Deaf, or Hearing Impairment
    8. I/DD-Intellectual/Development Disability
    9. Life Alert
    10. Mental Illness
    11. Mobility Impairment: Wheelchair
    12. Other Mobility Impairment
    13. Project Life Alert
    14. PTSD (Post Traumatic Stress Disorder)
    15. Service Animal
    16. Slight Impairment/Blind
    17. Speech Impairment
    18. Other (Please Explain in Next Option)

    (Select all that apply)

50. Other:
52. Describe any of the registrant's life threatening medical concerns: (allergies, seizures, etc)*
54. Does the individual have a medical condition that requires special equipment at home?*
    -- Select One --YesNo
55. Are Family Members or Aides Present 24 hrs. a day?*
    -- Select One --YesNo
57. Please Check all items the Individual Utilizes:*

    1. Epi-pen
    2. Bottled Oxygen
    3. Oxygen Concentrator
    4. Hospital Bed
    5. Stair Lift

    1. CPAT Equipment
    2. Dialysis Equipment
    3. Refrigeration for Rx Medications
    4. Other please explain...
    5. None
58. Other:
60. Does the Individual or Family Have Access to Back-Up Power?*

    1. Generator
    2. Battery Pack
    3. No Back-Up Available
61. Service Animal Used?*
    -- Select One --YesNo
62. Name/Breed of Service Animal:
64. Does registrant use any products/equipment? (mobile apps, alert buttons, help buttons, etc)
66. Additional Information:
68. Registrant School/Employment Information
70. Does the registrant attend school or are they employed?*
    -- Select One --YesNo
71. Name of School or Employer
73. School/Employer Address
75. City
76. State
77. Zip Code
79. School/Employer Phone Number
80. Name of Contact
82. Email Address
83. Comments
85. Does registrant have a Social Worker/Case Worker?*
    -- Select One --YesNo
86. Name of Social Worker/Case Manager:*
88. Phone Number:
90. Please Tell Us About You:

    1. I am the Registrant with the Special Need
    2. I am the Guardian or Family Member of the Registrant With Special Needs
    3. I am the Caregiver of the Registrant With Special Needs
92. First Name
93. Last Name
95. Relationship to Registrant*
97. Emergency Contact Information
99. First Name*
100. Last Name*
102. Address*
104. City*
105. State*
106. Zip Code*
108. Phone Number
109. Cell Phone Number*
111. Email Address
112. Relationship to registrant:*
114. Is this person the Legal Guardian of the registrant?*
     -- Select One --YesNo
115. Does Contact Have Key to Home or Passcode to Alarms?*
     -- Select One --YesNo
117. Additional Emergency Contact Information
119. First Name*
120. Last Name*
122. Address*
124. City*
125. State*
126. Zip Code*
128. Phone Number
129. Cell Phone Number*
131. Email Address
132. Relationship to registrant*
134. Does Contact Have Key to Home or Passcode to Alarms?*
     -- Select One --YesNo
135. Is this person the Legal Guardian of the Registrant?*
     -- Select One --YesNo
137. Registrant Pictures
     If you have photos please upload
139. Registrant Photos
141. Acknowledgement

     I acknowledge that by checking the box below that the information being provided is truthful, current and valid and that I am authorized to submit it on my own behalf or as the legal guardian with authority to submit it on behalf of another. I further understand that by enrolling myself or someone else in the Clark Police Department Special Needs Registry that the personal information entered may be used by emergency personnel, including, but not limited to, law enforcement officers, emergency medical services, and fire department personnel in the event of a personal emergency or other emergency situation. I acknowledge that it will be my responsibility to keep the information on the registry up to date. It is further understood that completion of this form and participation in the Clark Police Department Special Needs Registry is voluntary and cannot guarantee and is not intended to convey and warrant, either express or implied, as to outcomes, promises, or benefits from the use of this form and participation in this program. Use of the Clark Police Department Special Needs Registry constitutes acknowledgment and acceptance of these limitations and disclaimers. 

     Electronic Signature:

     By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

143. I accept the above disclaimer *
     -- Select One --YesNo
144. Date:
     Date:
146. First Name*
147. Last Name*
149. Any questions please email BSoos@clarkpolice.org
Leave This Blank:


151. 1. Receive an email copy of this form.
152. Email address

     This field is not part of the form submission.

153. Submit Submit and Print

* indicates a required field