Special Needs Registration Form
1. The “Special Needs Form” must be updated at least every
six (6) months or as changes occur.
2. Click on the button to save and email the registration for to
the Township now. (may not work with people who use
Yahoo or gmail types of email or if your version of Adobe
Reader is older than version 7)
3. Click here to save the form to your hard disk to complete
and send to the Township at a later time.
4. Print this document after you fill it out and send via regular
mail to:
Township of North Brunswick
710 Hermann Road
North Brunswick, N.J. 08902.
Attention “Special Needs”
Click here to save and email the Registration
Click here to save this form to your hard disk
Click here to print this Registration Form
North Brunswick Special Needs Registry
The following is strictly for identification with the minimum data requested from individuals with
disabilities and frail elderly who volunteer to register.
Personal/Residency Information
First Name: __________________________ Middle Initial: ____
Last Name: ___________________________________________
Sex Male Female
DOB____________ Date Form Completed: __________
Type of Residence: Private Special Needs Public Housing
Facility/Residence/Community Name:______________________________
Street Address: ________________________________________ *Not a PO Box
Address Line 2: ________________________________________
Apartment Building Name and Number: _____________________________
Floor Level: __________
Municipality/City: ______________________________________________
Phone Number: ________________________
Cell Phone: ________________________
E-mail Address: _______________________________________________
How well do you understand the English language?
Well Not well Not well at all
Primary language spoken: _____________________
If Special Needs, Special Needs Residence Type:
Assisted Living Retirement Community Senior Housing
Group Home Residential Health Care Facility Other
How many people including yourself are in your household?
Live alone 1 other person 2 other persons 3 other persons
more than 3 people
Are you responsible for minor children living with you? Yes No
If yes, how many? ____________
Emergency Contact Information
First Name: __________________________ Middle Initial: ____
Last Name: ___________________________________________
Street Address: ________________________________________ *Not a PO Box
Address Line 2: ________________________________________
City: ______________________________ State: ______ Zip Code: ___________
Phone Number: _______________________Cell Phone : ____________________
Fax Number: _______________________
E-mail Address : _______________________________________
The following information will further help us prepare for your evacuation
Do you have pets living with you? Yes No
Do you have a service animal?
Yes No
Are you bed bound?
Yes No
Weight Range
Less than 300 lbs. 300 lbs. or over
Special Needs Directory Page 2 of 3
Special Needs Directory Page 3 of 3
Walk with the assistance of :
No assistance Another person Cane Crutches Walker
Service Animal Other
Do you use a Wheelchair or scooter? Yes No
Type: Manual wheelchair Motorized wheelchair Scooter
Sight Impaired? No impairment Need glasses Blind
Hearing Impaired? No impairment Hearing aid Deaf
Check all items that apply :
Use Oxygen
Use respirator
Cognitive Impairment
Alzheimer/ dementia
Developmental disability
Mental Health condition
Evacuation Transportation Requirement
Do you require transportation? Yes No
If yes:
Standard transportation Yes No
Can you slide transfer? Yes No
Do you need vehicle with a lift? Yes No
Must be transported by Ambulance? Yes No
The following information will be helpful for your possible stay at an Emergency
Do you have :
Personal Emergency Kit? Yes No
Medication list? Yes No
File/Vial of Life? Yes No
Food Allergies? Yes No
If yes, specify ___________________________________________________
Other Allergies? Yes No
If yes, specify ___________________________________________________
Dialysis required?
Yes No
If yes, specify how often __________________________________________
This form was filled out by Self Family Member Other(name)__________________
I am submitting this form voluntarily, for the use by emergency personnel, in the event that I should
require assistance during an emergency.
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