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Special Needs Registry
NOTICE: BY SUBMITTING THIS FORM YOU AFFIRM UNDER OATH THAT YOU ARE LEGALLY RESPONSIBLE FOR THE PERSON NAMED BELOW FOR WHOM YOU HAVE PROVIDED INFORMATION AND THAT YOU CONSENT TO HAVE THIS INFORMATION SHARED AMONG LAW ENFORCEMENT PERSONNEL FOR ENROLLMENT IN COLUMBIANA COUNTY’S SPECIAL NEEDS REGISTRY. PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS.
PLEASE CONTACT US ANNUALLY TO UPDATE THE PICTURE AND IF ANY INFORMATION CHANGES. IF YOU HAVE ANY QUESTIONS, PLEASE SUBMIT THEM AT info@columbianacountyprosecutor.oh.gov
Last Name:
*
First Name:
*
Contact Middle Initial:
DOB:
*
Gender:
*
Height:
*
Weight:
*
Home Address:
*
City:
*
Enter your email:
*
Contact Phone Number:
Primary Language:
*
Build:
*
Hair Color:
*
Eye Color:
*
Glasses?
*
Yes
No
Social Security Number:
*
Driver's License/ID Number:
*
State:
Other Personal Characteristics: (Tattoos, Piercings, Scars, Marks, etc.)
*
Disability
Alzheimer's
Autism
Deaf
Cognitive Ability
Other Disability:
Method of Communication:
*
Verbal
Non-Verbal
Sign Language
Written
Speech Assistance Device
Comment in reference to communication
Does the registrant own a motor vehicle?
*
Yes
No
Type of Vehicle:
License Plate:
Emergency Contact Information - First
Contact Last Name:
Contact First Name:
Middle Initial:
Address:
*
Email Address:
*
Relationship to Registrant:
*
Emergency Contact Information - Alternate
Contact Address:
Contact City:
Contact Email Address:
Relationship to Registrant
Describe any of the registrant’s life-threatening concerns: (food or medical allergies/seizures/etc.)
*
If the registrant uses an Epi-pen please provide location where it is stored
Are there any triggers which affect the registrant? (loud noises/bright lights/etc.)
Are there any calming methods used for the registrant?
Does the registrant frequent or gravitate to any locations in particular? (water/playground/old house/etc.)
Please add any additional information you may think will be helpful for first responders to know regarding the registrant
Upload Picture of Registrant
*
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Contact Us:
135 South Market Street
Lisbon, OH 44432
Phone: 330-420-0140
Fax: 330-424-0944
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Divisions
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Columbiana County
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