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2. 
4. Person with Special Needs
6. This section is for the person with special needs only. Please do not put your personal information.
8. New Form or Renewal/Update:
9. Choose Type*
   -- Select One --RenewUpdateNew
11. Last Name*
12. First Name*
13. Middle Name
14. Gender*

    1. Male
    2. Female
16. Date of Birth*
    Date of Birth
17. Age*
18. Nickname (any name individual responds to):
20. Type of Disability or Special Need (may include medical issues):*
22. Eye Color*
23. Height*
24. Weight*
25. Build
27. Hair Color*
28. Hair Style
29. Facial Hair
30. Complexion
32. Scars/Marks/Tattoos (Location on body of each):
34. Street Address*
35. City*
36. State
    Tennessee
37. Zip Code*
39. Home Phone
40. Cell Phone
42. Employer/School
43. Phone Number
45. Language Spoken*
46. Method of Communication (speech, sign language, etc.):*
48. Identification Worn or Available:
52. Inclination for wandering or characteristics that may attract:*
54. Favorite attractions and locations where person may be found:*
56. Name and phone numbers of known friends or acquaintances:
58. Name
59. Phone Number
60. Relationship
62. Name
63. Phone Number
64. Relationship
66. Name
67. Phone Number
68. Relationship
70. Best methods of approach (please include approach and de-escalation techniques):*
72. Any other relevant information:
74. Information such as: favorite toys, names most likely to generate a positive response, reinforcers that are used, suggestions for de-escalation and/or cooperation (i.e., likes to hold certain object). Please include any information as WHAT NOT TO DO (i.e.: physical and/or direct eye contact, bright lights, loud noises, etc.)
78. Your Contact Information
80. Full Name*
81. Date of Birth*
    Date of Birth
82. Age*
84. Cell Phone*
85. Home Phone
86. Work Phone*
88. Relationship*
89. Email Address*
91. Address (if different)
93. Work Address*
95. Secondary Emergency Contact
97. Full Name*
98. Date of Birth*
    Date of Birth
99. Age*
101. Cell Phone*
102. Home Phone
103. Work Phone*
105. Relationship*
106. Email Address*
108. Address (if different)
110. Work Address*
112. Upload Your Photo:
114. Through this form, the Bartlett Police and Fire Departments will collect information that can identify you or a family member. Such identifying information may include your name, date of birth, e-mail address, mailing address and other similar information (“personal data”) when it is voluntarily submitted. The Bartlett Police and Fire Departments will use your personal data to respond to the requests for police/fire service you make of us and/or interacting with the persons named. We may refer to your personal data to better understand your needs and how we can improve our services in relation to you and/or your family. It is acknowledged that it is your responsibility to ensure that the information collected is current and valid, and that the Bartlett Police Department is notified in writing of any changes. All persons registering in this program will be required to update this information annually or verify that there have been no changes. Failure to update will result in your removal from the registry.
     
     It should be noted that the intended use of this form is to ensure the best possible response to a call for service by our Police and Fire Departments. This is in no way intended to limit the responding officers’ or fire fighters’ abilities or authority while responding to the call for service. It is our hope that this registration process will lead to the best possible outcome to any call for service.
     
     Your digital signature below signifies that the above information is true and accurate and that the person providing this information is authorized to do so.
116. Signature*
117. Date*
     Date
Leave This Blank:


119. 1. Receive an email copy of this form.
120. Email address

     This field is not part of the form submission.

121. Submit Submit and Print

* indicates a required field