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Special Needs Notification Form

  1. The information you provide could be important to first responders during an emergency involving a person with special needs.

  2. What would you like to do? Select one only.*

  3. Information About the Person with Special Needs

  4. Check all that apply:

  5. General Symptoms - Check all that apply.

  6. Your Information

  7. Please provide your information so that we may contact you should we have further questions or follow up with submissions.

  8. 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.

  9. Leave This Blank:

  10. This field is not part of the form submission.