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Jupiter Police Department Special Needs Registry
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How to Register
To register for the Special Needs Registry, complete the form below, print it and turn it into the Jupiter Police Department. Parents and caregivers may enroll a person of any age with any type of medical condition or disability, including but not limited to: Autism Spectrum Disorder, Alzheimer’s or Dementia, Bipolar Disorder and Down Syndrome. Adults with special needs may also enroll themselves.
What happens once the person is registered?
When a Police Officer has contact with the person on this form, our 911 center can provide us with the information needed to successfully interact and communicate with your loved one, as well as provide us with your contact information.
To see a listing of frequently asked questions
Please visit our Special Needs Registry Page
CONTACT INFORMATION
Person with Special Needs:
First Name
Middle Name
Last Name
Date Of Birth
Race
-- Select One --
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Gender
-- Select One --
Male
Female
Hair Color
Eye Color
Weight
Distinguishing Features (Scars/Birthmarks Tattoos:)
RESIDENCE INFORMATION
Address
City
State
Zip
PARENT OR GUARDIAN INFORMATION
First Parent or Guardian
Name
Primary Phone
Secondary Phone
Place of Employment
Second Parent or Guardian
Name
Primary Phone
Secondary Phone
Place of Employment
DISABILITY / SPECIAL NEED
Primary Diagnosis:
Co-Existing Diagnosis:
Notes:
EMERGENCY CONTACT INFORMATION
First Emergency Contact
Name
Address
City
Zip
Phone Number
Second Emergency Contact
Name
Address
City
Zip
Phone Number
PLEASE READ AND AGREE
By checking the box below I agree, I am the lawful and legal parent and/or guardian of the person with special needs listed in this safety roster:
I agree
Relationship
I agree and understand the information provided to the Jupiter Police Department is for law enforcement to have all the necessary information to better handle a situation and that information may be subject to public records laws, - however, special needs are protected under FSS 252.355(5) and will be redacted when necessary
I agree
RELEASE OF INFORMATION
I, hereby give my permission for the Jupiter Police Department to retain and distribute the information contained in this registration form to other first responder personnel for the sole purpose of identification and protection of the person identified above in an emergency or crisis situation.
I agree
Signature
Please Print this form and sign above
Final Instructions
Please fill out the form in its entirety and click the print button below. After printing the form please bring it to the
Jupiter Police Station at 196 Military Trail, Jupiter, FL 33458.
Please note The process may take up to two (2) weeks to be fully processed. You will receive a wrist band with a “number” when you register and an identification card that will be mailed to you from the police department.
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