Register Don’t want to fill in the form below? Print and Mail in Form (Word document) Are you registering for yourself?(Required) Yes No If no, what is your name and relationship to the Registrant? Registrant’s InformationFirst Name(Required) Last Name(Required) Alias or Preferred Name (optional) Primary Telephone Number(Required)Secondary Telephone NumberEmail Preferred Language English Spanish Other If other, please state language preference Date of Birth(Required) Ethnicity Weight (in lbs.) Height Municipality (select one)(Required)Alloway Twp.Carneys Point Twp.Elmer BoroughElsinboro Twp.Mannington Twp.Lower Alloways Creek Twp.Oldmans Twp.Penns Grove BoroughPennsville Twp.Pilesgrove Twp.Pittsgrove Twp.Quinton Twp.Salem CityUpper Pittsgrove Twp.Woodstown BoroughUpload a photo of yourselfMax. file size: 5 MB.Gender(Required) Male Female Physical / Primary Address(Required) City / State / Zip(Required) Secondary Physical Address (if applicable) DisabilitiesCheck all that apply to the registrant: Alzheimer’s/ Dementia Autism Blind / Sight Impairment (excluding corrective lenses) Combative/ History of combative behavior Deaf / Hearing Impairment Diabetic Down Syndrome Epilepsy Hallucinations Hoarding Disorder Mobility Impairment Morbid Obesity Non-Verbal PTSD Risk for Elopement (runs away) Self-Injurious Behavior Speech Impairment Substance Use Disorder Suicidal / History of Suicide Attempt(s) Tourette's Syndrome Uses Sign Language and/or Written Communication Only Verbally Abusive Behaviors Please describe any Physical, Mental Health, Intellectual/ Developmental Disabilities not listed above:Other InformationCase WorkerDoes this person have a Case Worker working with them?(Required) Yes No Unknown / Unsure If yes, Case Worker First & Last Name Agency the Caseworker works for Contact Information of Caseworker (phone, address, etc.) Motor VehiclesDoes the registrant have access to a motor vehicle?(Required) Yes No Unknown / Unsure If yes, License Plate # State Vehicle is registered in Make & Model of Vehicle Color of Vehicle Does the registrant have access to a SECOND motor vehicle?(Required) Yes No Unknown / Unsure If yes, License Plate # State Vehicle is registered in Make & Model of Vehicle Color of Vehicle Miscellaneous InfoDoes the registrant frequent / gravitate to any locations in particular?(Required) Yes No Unknown / Unsure If yes, please provide information as to these locationsDoes this person have a Service Animal?(Required) Yes No Unknown / Unsure If yes, please describe Service AnimalDoes the registrant have access to any weapons or firearms?(Required) Yes No Unknown / Unsure If yes, please provide type of weapons / firearmsDoes the individual have any emotional triggers that may upset them?(Required) Yes No Unknown / Unsure If yes, please describe:Are there any other life-threatening medical concerns, or individual information regarding the registrant that emergency personnel should know?(Required) Yes No Unknown / Unsure If yes, please describe:Emergency Contact InformationPrimary Emergency ContactEmergency Contact Full Name (First & Last)(Required) Emergency Contact Primary Phone(Required) Emergency Contact Secondary Phone Emergency Contact Primary / Physical Address(Required) Emergency Contact's Email(Required) Relationship to Registrant May we contact this person to update the registrant’s information? Yes No Unknown / Unsure Secondary Emergency ContactSecondary Emergency Contact Full Name (First & Last) Secondary Emergency Contact Primary Phone Secondary Emergency Contact Secondary Phone Secondary Emergency Contact Primary / Physical Address Secondary Emergency Contact's Email Secondary Contact's Relationship to Registrant May we contact this person to update the registrant’s information? Yes No Unknown / Unsure ACKNOWLEDGMENTI acknowledge that by checking the box below that the information being provided is truthful, current, and valid and that I am authorized to submit it on my own behalf or as the legal guardian with authority to submit it on behalf of another. I further understand that by enrolling myself or someone else in the Salem County Special Needs Registry that the personal information entered may be used by emergency personnel, including, but not limited to, law enforcement officers, emergency medical services (first aid/paramedics), and fire department personnel in the event of a personal emergency or other emergency situation. I also acknowledge that it will be my responsibility to keep the information on the registry up‐to‐date. It is further understood that completion of this form and participation in the Salem County Special Needs Registry is voluntary and cannot guarantee and is not intended to convey and warrant, either express or implied, as to outcomes, promises, or benefits from the use of this form and participation in this program. Use of the Salem County Special Needs Registry constitutes acknowledgement and acceptance of these limitations and disclaimers.Please Acknowledge Yes, I understand and acknowledge the above paragraph Terms & Conditions I have read and understand the Terms & Conditions to the Salem County Special Needs Registry NameThis field is for validation purposes and should be left unchanged. Δ View our Terms & Conditions.
