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Special Needs Registry

  1. Clark Police Department-Special Needs Registry

    The Clark Police Department Special Needs Registry is a voluntary service open to all citizens with disabilities or specialized medical needs or equipment who reside, attend school, or are employed in Clark. The registry was created to help police officers and other emergency personnel, better assist residents with special needs in the event of an emergency by providing those first responders with vital information regarding a registrant's disability, emergency contact information, physical description, and current photograph.

  2. Tell Us About the REGISTRANT with Special Needs
  3. Communication
  4. Special Needs
  5. What is the registrant's special need? *

    (Select all that apply)

  6. Please Check all items the Individual Utilizes:*
  7. Does the Individual or Family Have Access to Back-Up Power?*
  8. Registrant School/Employment Information
  9. Please Tell Us About You:
  10. Emergency Contact Information
  11. Additional Emergency Contact Information
  12. Registrant Pictures
    If you have photos please upload
  13. Acknowledgement

    I 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 Clark Police Department 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, and fire department personnel in the event of a personal emergency or other emergency situation. I 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 Clark Police Department 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 Clark Police Department Special Needs Registry constitutes acknowledgment and acceptance of these limitations and disclaimers. 

    Electronic Signature:

    By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

  14. Any questions please email
  15. Leave This Blank:

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