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Special Needs Registry

Tell Us About the REGISTRANT with Special Needs

What is th Registrant's Special Need? Check all that apply
Please Check ALL the items the individual Utilizes
Does the Individua or Family Have Access to Back-Up Power?

Registrant School / Employment Information

Please Tell Us About You:

Emergency Contact Information

Secondary or Additional Emergency Contact Information

Upload File


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 Verona 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 event of a personal emergency or other emergency situation. I 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 Verona 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 Verona Police Department Special Needs Registry constitutes acknowledgment and acceptance of these limitations and disclaimers.

Electronic Signature:

By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

Thanks for submitting!
Please Contact with any questions.

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