Form Center

2. The information you provide could be important to first responders during an emergency involving a person with special needs.
4. What would you like to do? Select one only.*

   1. Input information for the first time

   1. Change original information

   1. Please remove information
6. Information About the Person with Special Needs
8. First Name
9. Last Name
11. Address1
13. Address2
15. City
16. State
17. Zip
19. Primary Telephone for Residence
20. Secondary Telephone for Residence
22. Check all that apply:

    1. Blind or visually impaired
    2. Cognitive impairment that can involve memory, language, thinking and judgement issues
    3. Deaf or hard of hearing
    4. Physically linked to equipment required to sustain his or her life
    5. Bedridden, uses a wheelchair, or has a mobility impairment
    6. Psychiatric impairment
    7. Speech impairment
    8. Uses an electronic device for text communication utilizing a telephone line
24. Medical Diagnosis
26. General Symptoms - Check all that apply.

    1. Non-Verbal
    2. Medically Fragile
    3. On Medication
    4. Medical Alert Status
    5. Seizures
    6. Flight Risk
    7. Agressive in New Situations

    1. May Hurt Themselves
    2. Fears Flashing Lights
    3. Fears Being Touched
    4. Fears Loud Noises
    5. Tourette's Syndrome
    6. Experiences Sensory Overload
    7. Bedridden
28. Is there any other helpful information you can share?
30. Your Information
32. Please provide your information so that we may contact you should we have further questions or follow up with submissions.
34. First Name
35. Last Name
37. Email Address
38. Phone Number
40. 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.
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field