2. 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.
3. 
5. 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.
7. To see a listing of frequently asked questions
   Please visit our Special Needs Registry Page
9. CONTACT INFORMATION
   Person with Special Needs:
11. First Name
12. Middle Name
13. Last Name
15. Date Of Birth
16. Race
    -- Select One --American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
17. Gender
    -- Select One --MaleFemale
19. Hair Color
20. Eye Color
21. Weight
23. Distinguishing Features (Scars/Birthmarks Tattoos:)
25. RESIDENCE INFORMATION
27. Address
29. City
30. State
31. Zip
33. PARENT OR GUARDIAN INFORMATION
    First Parent or Guardian
35. Name
36. Primary Phone
38. Secondary Phone
39. Place of Employment
41. Second Parent or Guardian
43. Name
44. Primary Phone
46. Secondary Phone
47. Place of Employment
49. DISABILITY / SPECIAL NEED
51. Primary Diagnosis:
53. Co-Existing Diagnosis:
55. Notes:
57. EMERGENCY CONTACT INFORMATION
    First Emergency Contact
59. Name
61. Address
63. City
64. Zip
65. Phone Number
67. Second Emergency Contact
69. Name
71. Address
73. City
74. Zip
75. Phone Number
77. PLEASE READ AND AGREE
79. 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:

    1. I agree
80. Relationship
82. 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

    1. I agree
84. 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.

    1. I agree
86. Signature
    Please Print this form and sign above
88. 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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89. Print Only

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