• Exceptional Needs Registry

    Pleasanton Police Department

  • Description of person with special needs

  •  -
  • Birthdate*
     - -
  • Gender*

  • Next of Kin/Parent/Guardian Information

  •  -

  • Information that might be helpful to first responders in the event of an emergency

  • Prior wandering
  • Sensory issues

  • Reactions to touch
  • Reactions to sounds
  • Eye contact
  • Stimming behavior
  • Preferred communication mode
  • Weapons at living location*
  • If yes to question above, are the weapons locked?
  • Medical diagnosis*
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  • I am the lawful and legal parent and/or guardian of the person with special needs listed.

  • I understand the information provided to Pleasanton Police Services is for law enforcement to have all the necessary information to better handle a situation and that information may be subject to public records laws, however, special needs are protected under HIPAA laws and will be redacted when necessary.

  • hereby give my permission for Pleasanton Police Service to retain and distribute the information contained in this registration form to other first responder personnel for the sole purpose of identification and protection of the person identified above in an emergency or crisis situation.

  • Date
     - -
  • Should be Empty: