Special Needs Form

Special Needs Form

This form is designed to assist those who require special assistance in emergency situations. The information provided by you on this form will be held in the strictest confidence and will be shared only as necessary to ensure your safety in case of an emergency. The information will be entered into the Montclair Police Department’s dispatch computer database so that in the event of an emergency, the Police, Fire and Emergency Medical Services of the Township of Montclair can better serve you. If you have any questions regarding this form, please contact the Montclair Police Department at (973) 744-1234. Fill out and send to: Montclair Police Department, 647 Bloomfield Avenue, Montclair, NJ 07042

Name of Person Needing Special Assistance:


Please select one of the following zip code: Montclair, NJ: 07042   07043      

 Date of Birth:   

Home Telephone Number:  

Alternate Telephone Number:    

Email address: 

Information regarding the person needing special assistance, for example, an individual with a hearing or vision impairment, or someone who uses a wheelchair, or remains in a bed, or an individual w/autism: 

Physician/Healthcare Provider:  

Healthcare Telephone Number:

MedicAlert member              

MedicAlert Phone number:  

If you have a File of Life, where is it kept? 


Emergency Contact Person/Parent/Guardian

Name :         

Relationship to Disabled Person: 



State    Zip 

Home Telephone Number    

   Alternate Telephone Number:   

E-Mail Address: 

What information should police/fire/emergency medical services know to expedite care in case of an emergency? 




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