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 City of Denver Special Needs Registry


Emergency Response Registry for People with Disabilities


Submit your personal medical information to Denver's 9-1-1 call center so that dispatchers will have advance warning of any special needs or disabilities you may possess and can respond appropriately in the event of an emergency. DISCLAIMER: The information you submit will remain confidential and will be visible to the dispatcher when a call is received from the telephone number provided below, absent technical difficulties, helping them to respond to an emergency. This registry is for informational purposes only. Entering data in this registry does not guarantee that a specific emergency situation will be handled in any particular order or manner.

If you have a current emergency, please call 9-1-1 immediately. Providing information on this registry is for future informational purposes and is not a substitute for reporting an emergency.

The attached Authorization to Release Records form is also requested as part of this registry



(FOR DENVER RESIDENTS ONLY)
CONFIDENTIAL

9-1-1

IMPORTANT EMERGENCY MEDICAL OR DISABILITY INFORMATION
(This information is kept Confidential beyond its intended emergency service use)

Using the lines below, please describe important medical or disability information about yourself to assist First Responders, i.e. Police, Fire and EMS. Having this information allows them to provide the best course of action to you in an emergency. The information you provide here will be visible to the dispatcher when you dial 9-1-1 from your telephone.



required First Name (required)


required Last Name (required)


required Address (required)


required City (required)


required State (required)


Zip


required Telephone (required)


Cell


Text Pager


Your EMail address


Name of Complex and Unit Number


Type(s) of disability (Please check all that apply)
Blind
Partially sighted
Deaf
Hard of hearing
Wheelchair user
Electric
Manual


Are you an adult or juvenile?
Adult
Juvenile


Please provide a brief physical description:


Other mobility issues


List other devises used to assist you


Speech communication issues


Is there a service animal(s) in your home?
Yes
No


Provide name of service animal


List other animals in your home


List any additional important information here:


Emergency person to contact


Emergency contact telephone


Emergency contact cell


Emergency contact text pager


I hereby authorize first responders of the City and County of Denver, including the Police Department, Fire Department, and Emergency Medical Service, to receive copies of medical records from the following persons or entities:


required I hereby authorize first responders of the City and County of Denver, including the Police Department, Fire Department, and Emergency Medical Service, to release copies of medical records to the following persons or entities:




Your Email Address (optional):
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Emergency Number:  911

 

Non-emergency Number
Police: 720.913.2000

 

Special Needs Registry

   

City Agency Information:  311
 
  
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