Special Needs Registry

Our Special Needs Registry is a volunteer registry of information by those with a mental or physical disability that would be helpful for emergency personnel to know when responding to a crisis.

"The purpose of human life is to serve, and to show compassion and the will to help others."

-Albert Schweitzer

Please complete this form to register special needs person with the Camp Hill Police Department.

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Your Contact Information

First Name *

Last Name *

E-mail Address *

Phone Number *

Special Needs Person

First Name *

Last Name *

Date of Birth *

Month

Day

Year

Race(s) *

Gender *

Height *

Weight *

Location

Address: Get Address from Map Marker

Map MarkerUse Location Address | Use My Current Location

Hint, click the map to add or drag a GPS Marker. Zoom in for a better view.

Organization / Building / etc

Street Address *

Apartment / Suite Number

City *

State *

Zip Code *

Information

Include school/work info, car info, triggers, calming methods, service animal, etc.

Additional Notes / Condition / Consideration *

Photo

Attach a photo (jpg, jpeg, png) of the person.

Emergency Contacts

Include as much contact information as possible, e.g. name, address, phone, etc.

Emergency Contact #1 *

Additional Emergency Contacts

Agree *

I understand that submitting a false report is punishable by law.

Leave this field blank

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Special Needs Registry

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