Special Needs Registry

The Middlesex Township Police Special Needs Registry is a voluntary service open to all citizens with disabilities who reside, attend school, or are employed in Middlesex Township. The registry was created to help police officers, and other emergency service personnel, better assist residents with special needs in the event of an emergency by providing those first responders with vital information regarding a registrant's disability, emergency contact information, physical description, and current photograph.

Please complete this form to register special needs person with the Middlesex Township Police Department.

Your Contact Information

First Name *

Last Name *

E-mail Address *

Phone Number *

Handle with Care Person

First Name *

Last Name *

Date of Birth *

Month

Day

Year

Race(s) *

Gender *

Height *

Weight *

Location

Get Address from Map Marker

Organization / Building / etc

Street Address *

Apartment / Suite Number

City *

State *

Zip Code *

Map Marker

Use Location Address Use My Current Location

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

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