TOWNSHIP OF DENNIS
OFFICE OF EMERGENCY MANAGEMENT
P.O. Box 204, 571 Petersburg Road
Dennisville, NJ 08214

SPECIAL NEEDS ONLINE FORM - 2008

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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571 Petersburg Road, Dennisville, N.J. 08214, Phone: 609-861-9700
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