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2. 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

4. Special Needs Person
6. First Name
7. Last Name
8. Nickname
9. 1. Male
   2. Female
11. Address
12. DOB
14. City
15. State
16. Zip Code
18. Home Phone
19. Cell Phone
20. Email Address
22. Personal Health History
24. Height
25. Weight
26. Eye Color
27. Hair Color
29. Medical Alert Worn

    1. Yes
    2. No
30. If yes, what type and where worn?
32. Scars, Marks, Tattoos
34. List any medical conditions that the Special Needs Person has been diagnosed with or is being treated for.
36. Information Specific to the Special Needs Person
38. Does the individual live alone?

    1. Yes
    2. No
39. Is he/she likely to wander off?

    1. Yes
    2. No
41. Is the Special Needs Person hearing impaired?

    1. Yes
    2. No
42. Is the Special Needs Person visually impaired?

    1. Yes
    2. No
44. Favorite attractions or locations where the individual may be found?
46. Location of bedroom or likely place to find the individual in the residence at night?
48. Behaviors or characteristics of the individual that may attract the attention of responders?
50. Actions that may trigger outbursts or irrational behavior of the individual?
52. Favorite toys, objects, discussion topics, likes or dislikes of the individual?
54. Is the Special Needs Person

    1. Verbal
    2. Non-Verbal
55. Preferred Method of Communication (If non-verbal, sign language, picture boards, written words, etc.)
57. Is there any other information that may be helpful to responders when coming in contact with this Special Needs Person?
59. Emergency Contact Information
61. Emergency Contact #1
63. First Name
64. Last Name
65. Relationship
67. Address
69. City
70. State
71. Zip Code
73. Home Phone
74. Cell Phone
75. Other Phone
77. Emergency Contact #2
79. First Name
80. Last Name
81. Relationship
83. Address
85. City
86. State
87. Zip Code
89. Home Phone
90. Cell Phone
91. Other Phone
93. Emergency Contact #3
95. First Name
96. Last Name
97. Relationship
99. Address
101. City
102. State
103. Zip Code
105. Home Phone
106. Cell Phone
107. Other Phone
109. 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.

111. Person Completing Form
112. Relationship to Registree
113. Date
Leave This Blank:


115. 1. Receive an email copy of this form.
116. Email address

     This field is not part of the form submission.

117. Submit

* indicates a required field