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Special Needs Registry Form

  1. The Village of Whitefish Bay Police Department recognizes that some members of our community may have special needs, or may react differently when coming into contact with police officers or firefighters during an emergency situation. With this in mind, we’ve created a Special Needs Registry.

    The Special Needs Registry is available for all residents requiring special needs resulting from a physical, emotional, or medical condition (i.e. dementia, autism, etc.). Information provided is maintained in a confidential database which will assist emergency responders in providing a more informed response to those with special needs during an emergency.  If you are interested in participating in the Special Needs Registry, please fill out and submit the form below.

    If you wish to send a photo of the Special Needs Person, please send the photo separately to Lt. Andy Mroz at: a.mroz@wfbvillage.gov

  2. Special Needs Person
  3. Personal Health History
  4. Medical Alert Worn
  5. Information Specific to the Special Needs Person
  6. Does the individual live alone?
  7. Is he/she likely to wander off?
  8. Is the Special Needs Person hearing impaired?
  9. Is the Special Needs Person visually impaired?
  10. Is the Special Needs Person
  11. Emergency Contact Information
  12. Emergency Contact #1
  13. Emergency Contact #2
  14. Emergency Contact #3
  15. IMPORTANT:

    Please review the following before signing and/or submitting this form:

    Responding to this form is strictly voluntary. The information on this form will be added to the Whitefish Bay Police Department’s record management system, and may be distributed to emergency responders in order to better care for you or your family members. The Village respects your right to confidentiality and will strive to ensure that your personal information remains confidential. However, by definition of this form, once submitted, is a public record, and may be subject to disclosure under WI Stat.§19.35, except as otherwise exempted by law. The Village does not collect or maintain information about you that is not essential for your safety and well-being. By completing this Special Needs Registry form, I acknowledge that the information provided herein is accurate, and was submitted voluntarily for the sole purpose of assisting Police, Fire and Emergency Response Departments in more effectively responding to a potential emergency in or near my residence. I, therefore, authorize the use of this information for those purposes.

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  17. This field is not part of the form submission.