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TOWNSHIP OF DENNIS |
SPECIAL NEEDS ONLINE FORM - 2008
Name of person with Special Needs:
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Description of Special Needs:
Dialysis Patient Diabetic Hearing Impaired TTY/TDD |
Oxygen Blind Uses Seeing Eye Dog Language Barrier |
| Additional Information:
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Special Instructions:
- Address (Required) - Address - City (Required) - State (Required) - ZIP/Postal Code (Required) - Home Phone (Required) - Work Phone - Date (Required) |
THEINFORMATION 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. 571 Petersburg Road, Dennisville, N.J. 08214, Phone: 609-861-9700 |
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