Special Needs Registry Form

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SPECIAL NEEDS SERVICES INFORMATION

TO ALL COMMUNITY MEMBERS: The Maplewood Police Department is seeking voluntary emergency contact information for any person (of any age) that are affected by any form of altered mental status including Autism, Dementia, Bi-Polar Disorder, Schizophrenia, or other illness, condition, or “Special Need” that may cause them to become impaired.

Police Officers receive specific training to follow protocols when they contact persons with “Special Needs”. It would greatly help if The Maplewood PD was able to understand who the person is prior to making contact. This prior knowledge will aid in better communication which will lead to a safer resolution for all involved parties.

*This information is solely entered in our computer system.

It is intended for information purposes only and will not be shared.*

The Maplewood Police Department can enter specifics such as:

  • Noise, Sound, Touch sensitivities
  • Medication they may be taking
  • Places they frequent
  • Topics to easily discuss to put the individual at ease

Furthermore, after the individual’s needs are registered (see form below), they will be provided with an Identification Card, which if kept on their person, can assist an Officer in identifying the individual or contacting a family member/guardian.

Sample Card:

Sample Card FrontSample Card Rear

Be Advised: All of the information provided below will be put into our CAD system, which will provide our first responders with all of the vital information. *Any and all information provided in the form is provided voluntarily.*

For more information please contact Maplewood Police Department at (973) 762-3400 or

Ptl. Jones at Mjones@twp.maplewood.nj.us for any questions regarding the information provided,

Thank you!

Applicant Information
Please complete all fields.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png.
Please describe applicant's medical condition.
1) Emergency Contact Information
2) Emergency Contact Information (Optional)