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2. The Lincoln Park Police Department Special Needs Registry is a voluntary service open to all citizens with disabilities who reside, attend school, or are employed within the Borough of Lincoln Park. The registry was created to help police officers and other emergency personnel better assist individuals 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.

   NOTE: All individuals who are of legal age (where there is no Power of Attorney or guardianship) can only register themselves.

4. REGISTRANT INFORMATION
6. First Name*
7. Middle Name
8. Last Name*
9. Suffix
11. Address*
13. City
14. State
15. Zip Code
17. Home Phone #*
18. Cell phone #*
20. Date of Birth*
21. Driver's License Number (if applicable)
23. Race*
24. Gender*
25. Height*
26. Weight*
28. Hair Color*
29. Eye Color*
30. Complexion*
31. Facial Hair*
33. Scars/Marks/Tattoos*
35. Preferred Name
37. Please provide a recent photo of the person being registered*
39. Additional photo (if available)
41. PERSON COMPLETING THIS FORM (if different from above)
43. First Name*
44. Last Name*
46. Relationship to registrant*
48. VEHICLE INFORMATION (if applicable)
50. Does the registrant own or operate a motor vehicle?

    1. Yes
    2. No
52. License Plate #
53. State
54. Make
55. Model
57. License Plate #
58. State
59. Make
60. Model
62. Does the registrant own or operate a bicycle?

    1. Yes
    2. No
64. Make
65. Model
66. Speeds
67. Color
69. COMMUNICATIONS: (Verbal, Non-Verbal, Sign Language, Speech Difficulty, Picture Communication, Assisted Communication, Non-Communicative, Talker, etc.)
71. BEHAVIORS/CONSIDERATIONS: (Touch Sensitivity, Noise Sensitivity, Light Sensitivity, Combative, Self-Injurious, Water Attractive, Flight Risk/Wanders, Disrobes, Lack of Eye Contact, etc.)
73. If runs or wanders, where would he/she go? (Specify places frequented):
75. Known triggers? (Specific sound/light/gesture that bothers him/her):

    ALL INFORMATION WILL BE HELD IN THE LINCOLN PARK POLICE DEPARTMENT'S DATABASE, WILL BE ONLY ACCESSED BY OUR OFFICERS, AND WILL NOT BE DISSEMINATED TO THE PUBLIC. THE INFORMATION PROVIDED IS VOLUNTARY, BUT THE MORE INFORMATION YOU PROVIDE THE BETTER WE WILL BE ABLE TO ASSIST.

77. EMERGENCY CONTACT #1: First Name*
78. Last Name*
80. Relationship*
82. Address1
84. Address2
86. City
87. State
88. Zip
90. Home Phone
91. Cell phone*
93. Email*
95. EMERGENCY CONTACT #2: First Name*
96. Last Name*
98. Relationship*
100. Address1
102. Address2
104. City
105. State
106. Zip
108. Home Phone
109. Cell Phone*
Leave This Blank:


111. 1. Receive an email copy of this form.
112. Email address

     This field is not part of the form submission.

113. Submit

* indicates a required field