TOWNSHIP OF DENNIS OFFICE OF EMERGENCY MANAGEMENT P.O BOX 204, 571 PETERSBURG ROAD DENNISVILLE, NJ 08214

2010 SPECIAL NEEDS FORM

NAME OF PERSON WITH SPECIAL NEEDS:

NAME:_________________________________________ PHONE#:___________________

ADDRESS:__________________________________________________________________

CITY:_________________________________ STATE:___________ ZIP:_______________

DESCRIPTION OF SPECIAL NEEDS:

____ WHEELCHAIR BOUND ____ DIALYSIS PATIENT ____ DIABETIC

____ HEARING IMPAIRED ____ TTY/TDD ____SPECIAL MEDICATIONS

____ OXYGEN ____BLIND ____USES SEEING EYE DOG ____LANGUAGE BARRIER

ADDITIONAL INFORMATION:

1.________________________________________________________________

2.________________________________________________________________

3.________________________________________________________________

SPECIAL INSTRUCTIONS:

1.________________________________________________________________

2.________________________________________________________________

3.________________________________________________________________

INDIVIDUAL COMPLETING FORM:

NAME:_________________________________________ PHONE#:____________________

DATE:____________________________

THE INFORMATION CONTAINED ON THIS SPECIAL NEEDS FORM MAY INVOLVE PERSONAL

MEDICAL INFORMATION WHICH IS NOT SUBJECT TO THE STATE RIGHT-TO-KNOW LAWS.

THE INFORMATION ON THIS FORM IS CONSIDERED PERSONAL AND PRIVATE AND IS

PROVIDED FOR THE SOLE PURPOSE OF DEVELOPING A SPECIAL NEEDS DATABASE TO BE

UTILIZED BY THE TOWNSHIP OF DENNIS OFFICE OF EMERGENCY MANAGEMENT, AND/OR

ANY OF ITS DESIGNATED AGENTS ASSOCIATED WITH THE 9-1-1 DISPATCH CENTER.