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S.A.F.E.R. ONLINE REGISTRATION

MPD Special Needs Registry

The special needs registry is intended to assist first responders with individuals who require additional or unique support due to physical, developmental, intellectual, emotional, or behavioral conditions. This information will remain confidential, for official use only, and only used by the City of Milwaukee’s Fire or Police departments, and the Department of Emergency Communications.

Is this a renewal application? *

Yes
No

Person with Special Needs Information:

Name *

First

Middle

Last

Nickname/Preferred Name:

Date of Birth: *

Sex: *

Race: *

Weight: *

Height: *

Primary Language: *

Eye Color: *

Hair Color: *

Scars / Marks / Tattoos:

Home Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Are There Weapons in the Home:

If yes, Please Provide a List of Weapons in Home:

Enter secondary address if the person with special needs does not live in the City of Milwaukee, but frequents another location such as a care center, work, or school. In this case, the secondary address will be the address entered into the computer-aided dispatch (CAD) system. If the person with special needs lives in the City of Milwaukee and has a secondary address, both locations will be entered into the CAD system.

Secondary Address:

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Email of Contact Person (if different)

Primary Diagnosis / Disability: *

Other Relevant Conditions:

No Sense of Danger
Blind
Deaf
Non-Verbal
Seizures
Combattive / Aggressive
Cognitive Impairment
Other (please describe below)

Preferred Method of Communication (verbal, written, sign, etc):

Alcohol / Drug Issues:

Prescription Medications:

Sensory Issues:

Identification Worn / Used (jewelry, medical alerts, GPS tracking device, ID card, etc):

Additional Locations this Person May be Found:

Best Approach Methods with this Person:

Favorite toys, objects, music, discussion topics (things that calm or relax):

Triggers / Dislikes:

Additional people person may contact or be with (include name and phone number:

Upload Photo:

Drag & Drop Files, Choose Files to Upload

Emergency Contact:

Name:

First

Last

Relationship:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Submitting Person

Submitting Person's Name *

First

Last

Submitting Person's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Relationship: *

Home Phone:

Cell Phone: *

Work Phone:

IMPORTANT: REVIEW THE FOLLOWING BEFORE COMPLETING, SIGNING, AND SUBMITTING FORM: Check the box to indicate that you have read and understand. *

Filing out this form is strictly voluntary. Information provided may be made available to the Milwaukee Fire and Police departments and the Department of Emergency Communications to aid in the response of first responders to enhance awareness and preparedness. Responding personnel will continue to use established protocols when responding to calls for service. Participation in this program does not confer additional legal rights to the individual(s) listed herein.
Information provided does not supersede the professional judgment of responding personnel and may not be readily available to responding personnel based on the particular circumstances in each specific case. The information provided may be subject to disclosure under WI Stat. § 19.35, except as otherwise exempted by law. By completing this form, you acknowledge that you have read and understand the entire document, and that the information provided is accurate, and that you are an authorized caretaker or guardian of the person with special needs.
Information provided will be purged after one year; however, you may resubmit the information yearly.

Online Signature: *

Person with Special Needs Information:

Emergency Contact:

Submitting Person

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