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Special Needs Notification Form
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This form has been modified since it was saved. Please review all fields before submitting.
The information you provide could be important to first responders during an emergency involving a person with special needs.
What would you like to do? Select one only.
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Input information for the first time
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Information About the Person with Special Needs
First Name
Last Name
Address1
Address2
City
State
Zip
Primary Telephone for Residence
Secondary Telephone for Residence
Check all that apply:
Blind or visually impaired
Cognitive impairment that can involve memory, language, thinking and judgement issues
Deaf or hard of hearing
Physically linked to equipment required to sustain his or her life
Bedridden, uses a wheelchair, or has a mobility impairment
Psychiatric impairment
Speech impairment
Uses an electronic device for text communication utilizing a telephone line
Medical Diagnosis
General Symptoms - Check all that apply.
Non-Verbal
Medically Fragile
On Medication
Medical Alert Status
Seizures
Flight Risk
Agressive in New Situations
May Hurt Themselves
Fears Flashing Lights
Fears Being Touched
Fears Loud Noises
Tourette's Syndrome
Experiences Sensory Overload
Bedridden
Is there any other helpful information you can share?
Your Information
Please provide your information so that we may contact you should we have further questions or follow up with submissions.
First Name
Last Name
Email Address
Phone Number
If you have questions about the Special Needs Notification Form, contact Jacksonville Public Safety 9-1-1 Center Supervisors Kristy Smith or Jeff McCallister at 910 938-7585 or by e-mail at ksmith@jacksonvillenc.gov or jmccallister@jacksonvillenc.gov.
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