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TOWNSHIP OF DENNIS |
2008 SPECIAL NEEDS FORM
NAME
OF PERSON WITH SPECIAL NEEDS:
NAME:_________________________________________ PHONE#:___________________
ADDRESS:__________________________________________________________________
CITY:_________________________________ STATE:___________ ZIP:_______________
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:
1.________________________________________________________________
2.________________________________________________________________
3.________________________________________________________________
SPECIAL INSTRUCTIONS:
1.________________________________________________________________
2.________________________________________________________________
3.________________________________________________________________
INDIVIDUAL
COMPLETING FORM:
NAME:_________________________________________ PHONE#:____________________
DATE:____________________________
THE
INFORMATION 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.