red arrow Location:
571 Petersburg Road
Dennisville, N.J. 08214
Phone: 609-861-9700
County of Cape May
red arrow right Email: Main Office
Official Web Site of:
The Township of Dennis
County of Cape May
New Jersey
red arrowHours:
Dennis Township Administrative
Offices are open daily
from 8:30 a.m. to 4:00 p.m.
Monday thru Friday
red arrow right Email: Information
TOWNSHIP OF DENNIS
OFFICE OF EMERGENCY MANAGEMENT
P.O. Box 204, 571 Petersburg Road
Dennisville, NJ 08214

SPECIAL NEEDS ONLINE FORM - 2010

Name of person with Special Needs:
    - Name (Required)
    - Address (Required)
    - Address
    - City (Required)
    - State (Required)
    - ZIP/Postal Code (Required)
    - Home Phone (Required)
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:

Special Instructions:

Individual Completing Form:
    - Name (Required)
    - Address (Required)
    - Address
    - City (Required)
    - State (Required)
    - ZIP/Postal Code (Required)
    - Home Phone (Required)
    - Work Phone
    - Email
    - 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.

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Township of Dennis Official Web Site:
www.DennisTwp.org
2010 Township of Dennis. All rights reserved.
Dennis Township Seal image
Web Site Designed & Maintained by:
Power Of Production Studio
Web Comments to: Thomas H. Laughlin