Special Needs Registry

Please complete this form to assist Police Officers and First Responders with information of your family member with a special need(s) so the First Responders can identify and reunite the person with a special need(s) with their family. This Registry will also assist First Responders by providing information that will benefit them in responding to any calls for service or incidents so the Police Officers, First Responders are informed of the needs of your loved one.

This registry is confidential and is only accessible to employees of the York County Regional Police Department.

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

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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