Special Needs Registration

2. Shorewood Police Department

   The Shorewood Police Department recognizes that some residents and visitors may have special needs that impacts how they interact with first responders. With that in mind, we have developed a special needs registration form. 

   The information obtained will be used to enhance the safety of the community and provide a more informed response to those with special needs during an emergency.   If interested, please complete the special needs registration form below and click SUBMIT at the bottom of the screen. A PDF version of this form is available upon request.   

   Questions regarding the Special Needs Registry can be directed to Captain Fernando Santiago at 414-847-2610, or emailed at police@villageofshorewood.org.

4. First Name*
5. Last Name*
7. Nickname
8. Birthdate*
9. Sex
   -- Select One --MaleFemale
11. Address*
12. City
13. State
15. Phone*
16. E-mail*
18. Height
19. Weight
20. Eye Color
21. Hair Color
23. Does the person live alone?

    1. Yes
    2. No
24. Medical Alert worn

    1. Yes
    2. No
25. Are they likely to wander off?

    1. Yes
    2. No
27. Visually impaired?

    1. Yes
    2. No
28. Hearing Impaired?

    1. Yes
    2. No
29. Is the person:

    1. Verbal
    2. Non-verbal
31. List any favorite locations where the person may be found.
33. List any medical conditions that the person has been diagnosed or is being treated for.
35. Best method to interact/engage with the person.
36. Is there any information that may be helpful to first responders when coming in contact with this person? (i.e. triggers/toys/sounds/phrases)
38. Does the person have violent tendencies?

    1. Yes
    2. No
40. Emergency Contact information - 1
42. First Name*
43. Last Name*
45. Address1
47. Address2
49. City
50. State
51. Zip
53. Home Phone
54. Cell Phone*
56. Emergency Contact - 2
58. First Name
59. Last Name
61. Address1
63. Address2
65. City
66. State
67. Zip
69. Disclaimer

    Responding to this form is strictly voluntary. The information on this form will be added to the Shorewood Police Department’s record management system, and may be distributed to emergency responders in order to better care for you or your family members. Once submitted, this form is a public record, and may be subject to disclosure under WI Stat.§19.35, except as otherwise exempted by law. The Village does not collect or maintain information about you that is not essential for your safety and well-being. By completing this Special Needs Registry form, I acknowledge that the information provided herein is accurate, and was submitted voluntarily for the sole purpose of assisting Police, Fire and Emergency Response Departments in more effectively responding to a potential emergency in or near my residence. I, therefore, authorize the use of this information for those purposes.

71. Person completing the form
72. Relationship to registree
73. Date
Leave This Blank:


75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

* indicates a required field