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Operation Helping Hand - Special Needs Registration

Operation Helping Hand is a cooperative public safety program in DuPage County. It is designed to ensure the safety of those residents of DuPage County that are most vulnerable to emergencies and disasters, the elderly and infirmed and those with various disabilities. The information you provide about your health and medical condition may be shared with police, fire and other emergency workers to assist them in responding to a disaster or emergency. You may revoke your consent to sharing information at any time by sending a written request to DuPage County Office of Homeland Security and Emergency Management, 136 N. County Farm Road, Wheaton, IL 60187. Providing this information does not insure that you will receive special treatment, but your needs will be given consideration. By submitting this information, you consent to sharing the information on this form.

If you would rather print out and mail in the registration form, download the printable registration form.


* - denotes required fields
Registration Information
Prefix:
First Name:	*
Last Name:	*
Suffix:
House Number:	*
Street Direction:
Street Name:	*
Street Type:
Apartment:
City:	*
State:	IL
Zip Code:	*
Home Phone:	*
Cell Phone:
Email:
Gender:
Cross Street:
Birthdate:	*
Primary Language:

Next of Kin or Person Responsible for Healthcare
Prefix:
First Name:	*
Last Name:	*
Suffix:
Address:	*
City:	*
State:	*
Zip Code:	*
Home Phone:	*
Cell Phone:
Email:

Special Needs- Circumstances
Special Circumstances Required Assistance	I have visual impairment I need transportation I have hearing impairment I need assistance with basic daily care I have a mobility impairment I have a service animal I live alone I have a pet I have another disability (describe): NOTE: Please separate multiple items with a semicolon (;)
Special Needs- Equipment
Special Needs / Equipment (Check all that apply):	Oxygen Wheelchair, walker, cane Ventilator / Respirator IV Support Dialysis Other (list): NOTE: Please separate multiple items with a semicolon (;)

Other Information
Entered By:
Provided By:
Provided By Relationship:

You will be assigned a Registration number. Please record this number and the password you enter below so in the future you can update your profile when needed.
Password:	*
Password confirmation:	*

The County of DuPage

Wheaton, Illinois

Homeland Security and Emergency Management (OHSEM)

Operation Helping Hand - Special Needs Registration