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 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)
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