DuPage County IL – Homeland Security - Special Needs Registration

**Registration Information for Special Needs Program**
Field	Value
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: mm/dd/yyyy	*
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 Other Assistance: Check last box and describe in text box	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): Other Equipment: Check last box and list in text box	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:	*

Field

Value

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: mm/dd/yyyy

*

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

Other Assistance: Check last box and describe in text box

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):

Other Equipment: Check last box and list in text box

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:

*

Operation Helping Hand - Special Needs Registration