Special Needs Registry

2. Personal Information

   Please input the personal information of the special needs individual below.

4. Name (First, Middle, Last)*
6. Address for Point of Contact
8. City
9. State
10. Zip Code
12. Date of Birth*
13. Gender
15. Race
16. Hair Color
18. Primary Language
19. Eye Color
21. Identifying Features
25. Residential Information
27. Home Address*
29. City*
30. State*
31. Zip Code*
33. Neighborhood/Development Name
34. E-mail Address
38. Parent or Guardian Information
40. Name
42. Home Phone
43. Cell Phone
45. Place of Employment
46. E-mail Address
50. Additional Contact Information (First)
52. Name
54. Home Phone
55. Cell Phone
57. Place of Employment
58. E-mail Address
62. Additional Contact Information (Second)
64. Name
66. Home Phone
67. Cell Phone
69. Place of Employment
70. E-mail Address
74. Registry Information: Disability/Special Needs/Medical Needs:

    Please input the personal information of the special needs individual below.

76. Primary Diagnosis
78. Co-Existing Diagnosis
80. Additional Notes
82. Medications
84. Doctor
86. Please list any characteristics that are associated with this person

    (Examples include sensory issues, certain behaviors, physical aggression, calming strategies, trigger mechanisms, audio or visual aids, or previous dealings with police.)

88. What is the best method of communication with this individual?

    (Examples include words, pictures, electronic devices, etc.)

90. Check One

    1. I am the registered individual
    2. I am the parent or guardian of the registered individual
92. Name
93. My relationship to the registered individual
97. STATEMENT REGARDING RELEASE OF SPECIAL NEEDS REGISTRY INFORMATION

    I acknowledge and fully understand:

    1) That this Special Needs Registration is a “public record” as defined by Section 119.011, Florida Statutes, and as such is subject to disclosure as permitted or required by the Public Records Act (Chapter 119, Florida Statutes);

    2) That state law does not afford this Special Needs Registration, or related information provided to the City, with confidential or exempt status which would authorize the City to redact certain information or refuse the release of such information;

    3) That federal Health Insurance Portability and Accountability Act of 1996 (HIPPA) privacy protections do not protect health information from release by the City because the City is not a “covered entity” under HIPAA for purposes of this registry; and

    4) That given the aforementioned, I have no expectation of privacy in the information provided to the City on this form.

99. STATEMENT REGARDING PURPOSE OF SPECIAL NEEDS REGISTRY

    I acknowledge and fully understand:

    1) That the information I am providing to the City of Maitland (“City”) for the Maitland Police Department Special Needs Registry (“Special Needs Registry”) will be maintained in a database readily accessible to law enforcement officers and first responders so that it may assist such officers when responding to calls for service;

    2) That by enrolling myself or someone else in the Maitland Police Department’s Special Needs Registry, the personal information provided may be used by emergency personnel including, but not limited to, law enforcement officers, emergency medical services (first aid/paramedics), and fire department personnel in the event of an emergency situation; and

    3) That completion of this form and participation in the Maitland Special Needs Registry is voluntary. Participation in the Special Needs Registry does not guarantee and is not intended to create, convey or warrant, either expressly or impliedly, certain outcomes, rights, duties, promises, benefits, or special treatment based on the information provided to the Maitland Police Department upon registration and participation in this program.

101. RELEASE AND HOLD HARMLESS AGREEMENT

     For participation in this Special Needs registry, I, individually or on behalf of the registered person, as applicable, hereby waive, release, discharge, and hold harmless the City from and against all claims, losses, damages, personal injuries (including but not limited to death), or liability (including reasonable attorney’s fees), which directly or indirectly arise out of or result from any act or failure to act based on information received through the voluntary Special Needs Registry or which relates to the dissemination of information received through the voluntary Special Needs Registry.

     I represent by signing below that the information provided is truthful, and that I am authorized to submit it on my own behalf or as the parent or legal guardian with authority to submit it on behalf of another.

103. Printed Name
105. Date
Leave This Blank:


107. 1. Receive an email copy of this form.
108. Email address

     This field is not part of the form submission.

109. Submit

* indicates a required field