SPECIAL NEEDS REGISTRY

Laurens County Sheriff's Office

Sheriff Don Reynolds

Full Legal Name

Nickname or Preferred Name

Address

Race

Cell Phone (If no cell, list guardian's cell number)

Home Phone

Gender

Date of Birth:

Height

Weight

Hair Color

Eye Color

Scars/Piercings/Tattoos/Identifiers

What is the registrant's special need? (i.e. Autism, Alzheimer's, Mental Illness, PTSD...etc.)

Method of Communication: (Verbal, Non-Verbal, Sign Language, Written...etc.)

Does the registrant currently utilitize any tracking/health equipment? (Project Lifesaver, Life Alert)

Important Medical Concerns (Seizures, Allergies, Medications etc.)

Areas the registrant frequents (parks, church, employer, friends residences, neighbors). Include addresses if possible

Any triggers which affect the registrant (bright lights, loud noises etc.)

Are you a veteran?

List any sensory issues or preferences:

Calming Methods or Suggestions for Registrant

Name of School/Employer If Applicable

Address of School/Employer

School/Employer Phone

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Phone:

Image of Registrant

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I acknowledge that by signing below that the information provided is truthful, current, and valid and that I am authorized to submit it on behalf of myself or another. I further understand that by enrolling myself or someone else in the Laurens County Sheriff's Office Special Needs Registry that the personal information entered may be used by emergency personnel, including but not limited to, law enforcement, emergency medical services, and fire department personnel in the event of a personal emergency, call for service, or any other emergency situation. It is further understood that completion of this form and participation in this registry is voluntary and cannot guarantee a specific outcome, promise, or benefit from the use of this form and participation in this program.

Person Filling Out This Form

Relationship to Registrant

What is the Special Needs Registry?

The Laurens County Sheriff's Office Special Needs Registry is a voluntary service open to all citizens with disabilities who reside in Laurens County. The registry was created to help deputies and other emergency service personnel better assist residents with special needs in the event of an emergency by providing us with vital information regarding a registrant’s disability or medical condition, emergency contact information, a physical description and current photograph of the registrant.

How will the information provided help a person with special needs during an emergency or call for service?

The information contained in the registry can help in several different ways. When a deputy responds to a call for service, dispatchers relay that someone at that location is on the registry. Depending on the type of call, the responding deputy can better assess the type of response necessary and request other appropriate resources accordingly. Deputies and other first responders can better gauge their responses. In addition, in the event that a person with special needs is reported missing, first responders will have current photographs and other vital information available that could aid in locating the missing person faster.

Who has access to the registrant's information?

Information provided is strictly confidential and will only be shared with first responders.

Our Special Needs Registry is a voluntary service open to all citizens with special needs who reside in Laurens County. This registry has been created to help deputies better assist residents in the event of an emergency by providing us with vital information regarding the registrants emergency contact information, a physical description, current photograph, and pertinent information regarding how best to communicate with the individual. We welcome any suggestions to help us better assess the type of response necessary.

Laurens County Sheriff's Office

216 W Main Street Laurens, SC 29360

Don Reynolds, Sheriff