SOUTH BRUNSWICK TOWNSHIP POLICE DEPARTMENT
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Special Needs Registry Form
First Name_______________________________ Middle Initial ________
Last Name _______________________________ Nickname (If Any) _______________________
Home Address_________________________________________________________________________
Home Phone _____________________________ Cell Phone______________________________
Date of Birth_________ Gender_______ Height_______ Weight________ Hair Color__________
Eye Color__________ Corrective Lenses _________ Scars/Piercings/Tattoos______________________
What is the registrant’s special need? (i.e. Autism, Alzheimer’s, Mental Illness etc.)
_____________________________________________________________________________________
_____________________________________________________________________________________
Method of Communication: (Verbal, Non-Verbal, Sign Language, Written, Speech Assistance Device)
____________________________________________________________________________________
What language(s) does the registrant speak or understand? _____________________________________
Does the registrant utilize any tracking/health equipment? (Project Lifesaver, Life Alert, Mobile App)
____________________________________________________________________________________
Life Threatening Medical Concerns? (Medicine, Allergies, Seizures etc.)
____________________________________________________________________________________
____________________________________________________________________________________
Areas that the registrant frequents (playgrounds, pools, stores, friend’s residence etc.)
____________________________________________________________________________________
____________________________________________________________________________________
Does the registrant gravitate towards water? If so can the registrant swim?
____________________________________________________________________________________
Raymond J. Hayducka, Chief
James E. Ryan, Deputy Chief
Any triggers which affect the registrant (i.e. loud noises, bright lights etc.)
____________________________________________________________________________________
Any calming methods used for the registrant
____________________________________________________________________________________
Does the registrant have a driver’s license? (If so list license number) ____________________________
Does the registrant own or frequently drive a vehicle? (If so list make, model color and license plate)
____________________________________________________________________________________
Does the registrant attend school or are they employed _________________
Name of School/Employer _______________________________________
School/Employer address _______________________________________________________________
School/Employer phone number ___________________________________
Emergency Contact Information
First Name_________________ Last Name ___________________ Relationship__________________
Home Address_________________________________________________________________________
Home Phone _____________________________ Cell Phone______________________________
I acknowledge that by signing below that the information being provided is truthful, current, and valid and that I am
authorized to submit it on my 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 South Brunswick Police Special Needs Registry
that the personal information entered may be used by emergency personal, including, but not limited to, law
enforcement officers, emergency medical services (first aid/paramedics), and fire department personnel in the event
of a personal emergency or other emergency situation.
It is further understood that completion of this form and participation in the South Brunswick Police 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.
By signing below, I also acknowledge that I understand the disclaimer.
_________________________________________________ ______________________
(Signature of the Person Filling out this Form) (Relationship to Registrant)
__________________________________________________ _____________________
(Print Name) (Date)
Pleasecompletetheapplication, scanandemailalongwithaphotographtoSpecialneedsreg@sbtnj.net
Be sure to include SNR or Special Needs Registry in the Subject field when emailing.
Applications canalso be mailedto or dropped offatSouth BrunswickPoliceHeadquarters
Spe Attn: Special Needs Registry, 540 Ridge Road, Monmouth Junction, NJ 08852
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