Fillable Special Needs Registry LHPD Fillable (Township of Long Hill)

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Special Needs Registry LHPD Fillable (Township of Long Hill)

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Long Hill Twp Police
Special Needs Registry
The Long Hill Twp Police Department is making it easier to help our citizens who may
be lost or have trouble communicating with officers.
Our Special Needs Registry is designed for residents who may be challenged with
developmental disabilities such as Autism, Dementia, Down Syndrome, or other special
needs. The program was created to better assist your loved ones who might be at a
higher risk for wandering from home and getting lost. By voluntarily registering, the
police will have access to personal information should they encounter an individual who
has difficulty speaking or identifying themselves.
Interested family members would be asked to complete a descriptive questionnaire
regarding their family member, providing the registrant’s height, weight, and other
information useful to first-responders, such as emergency contacts, a recent photo of
the individual and home address. The information would be kept on file at
headquarters and would be accessible at times such as during an encounter where an
individual can’t tell officers where he/she lives, or would work in cases where a person
is reported missing, so that their pedigree and photograph are immediately available
to responding police officers.
The program is voluntary and all the information kept confidential within the Long
Hill Twp Police Department.
To complete and file a registration form, or for more information please contact:
Ofc. Brian Engel
(908) 647-1800 ext 517
Bengel@longhillpolice.us
Long Hill Twp Police Department
264 Mercer St, Stirling NJ 07980
Office: 908-647-1800 Fax: 908-647-0355
www.longhillnj.gov/police
Serving Millington, Stirling, Meyersville, Gillette and Homestead Park
LONG HILL TWP POLICE DEPARTMENT
SPECIAL NEEDS REGISTRY
The Long Hill Twp Police Department Special Needs Registry is a voluntary service open to all citizens with disabilities who
reside, attend school, or are employed in Long Hill Twp. 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.
First Name Last Name
Middle Initial Nickname (if any)
Home Address
City, State and Zip
Driver’s License State Driver’s License Number
Email Address
Home Phone # Cell Phone #
Person Filling Out This Form (If Different from Above)
First Name Last Name
Relationship to registrant
Registered Vehicles
Does the registrant own or operate a motor vehicle?
Yes No
Registration State License Plate # Make Model Color
Registration State License Plate # Make Model Color
Does the registrant own or operate a bicycle?
Yes
No
Make Model Speeds Color
Registrant Identifiers
Date of Birth Gender Male Female Race Height (ft.) (Inches)
Weight (in pounds) Build (required) Hair Color Eye Color
Corrective Lenses: Contact Lenses Eye Glasses Prescription Sunglasses
Scars/Piercings/Marks/Tattoos (location):
Communication
Method of Communication
❑
Augmentative/Speech Assistance Device Non-Verbal Verbal Sign Language Written
What type of Augmentative/Speech Assistance Device does the registrant use?
What type of sign language does the registrant use?
What language(s) does the registrant speak or understand?
Registrant School / Employment Information
Does the registrant attend school or are they employed? Yes No
Name of School / Employer:
School / Employer Address:
School / Employer City, State and Zip:
School / Employer Phone # Contact:
(Additional School / Employer)
Name of School / Employer:
School / Employer Address:
School / Employer City, State and Zip:
School / Employer Phone # Contact:
Special Needs
What is the registrant’s special need? (Select all that apply)
❑
Alzheimers / Dementia
Mental Illness
❑
Autism
Mobility Impairment: Wheelchair
❑
Diabetes / Hyperglycemic (Type )
Mobility Impairment: Other
❑
Dialysis
Oxygen Dependent
❑
Epilepsy
Project Life Alert
❑
Electricity Dependent
PTSD (Post-Traumatic Stress Disorder)
❑
Hard of Hearing / Deaf, or other Hearing Impairment
Service Animal
❑
I/DD - Intellectual / Developmental Disability
Sight Impairment / Blind
❑
Life Alert
Speech Impairment
❑
Other
Describe any of the registrant’s life threatening medical concerns: (eg. food or medicine allergies, seizures, etc.)
Does the registrant use an Epi-pen? (If yes, please give location where it is stored) Yes No
Any Triggers which affect the registrant? (i.e., Loud Noises, Bright Lights)
Any Calming Methods used for the registrant?
Does the registrant frequent / gravitate to water, playgrounds, etc.? (If yes, give locations) Yes No
What products / equipment and with which vendor does the registrant have from Life Alert / Project Life Saver? (eg. pendant,
wristband, mobile app, push HELP button, etc.)
Does the registrant have a Social Worker / Case Worker assigned? Yes No
Name of Social Worker / Case Worker Phone #
Does the registrant have a service animal?
Yes
No
If yes, give the type/description, name and what the service animal assists with
Any other information that may be important?
Emergency Contact Information
First Name Last Name
Address
City, State and Zip
Home Phone # Cell Phone #
Relationship to the registrant
Is this person the Legal Guardian of the registrant? Yes No
Additional Emergency Contact Information
First Name Last Name
Address
City, State and Zip
Home Phone # Cell Phone #
Relationship to the registrant
REGISTRANT PICTURES - If you are mailing this form, please attach as many pictures of the registrant that you feel are necessary.
If you are scanning and emailing, please email the picture(s) as an attachment. PHOTO(S) SUBMITTED
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 Long Hill Twp 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 even
t of a personal emergency or other emergency situation. I also 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 Long Hill Twp 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 Long Hill Twp Police Department Special Needs Registry
constitutes acknowledgment and acceptance of these limitations and disclaimers.
I understand the above disclaimer (required)
Yes No
(Signature of the person filling out this form) (Date)
(Print Name)
Please complete all pages of this application, scan and email along with your pictures to:
Bengel@longhillpolice.us
If you prefer to mail the application along with the pictures, send to:
Long Hill Twp Police Department
Special Attention: Ofc. Brian Engel
264 Mercer Street
Stirling, NJ 07980
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Special Needs Registry LHPD Fillable (Township of Long Hill)

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Completed 14 July 2020

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