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Police/Office of Emergency Management (OEM)

Cranbury Township Special Needs Registry

The following information is strictly for identification purposes, with minimum data requested from individuals with disabilities, or frail and elderly participants who volunteer to register.

Personal/Residency Information

First Name

Middle Initial

Last Name

Sex

Male

Female

Age

Date Form Completed

Month

Day

Year

Type of Residence:

Private

Special Needs

Public Housing

Facility/Residence/Community Name

Street Address

* Not a PO Box

Floor Level

Phone number

Cell Phone

Email address

How well do you understand the English language?

Well

Not Well

Not at all

Primary language spoken

If Special Need, Special Needs Residence Type

Live alone

1 other person

2 other people

3 other people

more than 3 people

How many people including yourself are in your household

Live alone

1 other person

2 other people

3 other people

more than 3 people

Are you responsible for minor children living with you?

Yes

No

Emergency Contact Information

First Name

Middle Initial

Last Name

Street Address

* Not a PO Box

City

State

Zip Code

Phone number

Cell Phone

Fax Number

Email address

The following information will further help us prepare for your evacuation

Do you have a service animal?

Yes

No

Do you have pets living with you?

Yes

No

Weight Range

less than 300lbs.

300lbs. or over

Are you bed bound?

Yes

No

You walk with the assistance of:

No assistance

Another person

Cane

Crutches

Walker

Service Animal

Other

Do you use a Wheelchair or scooter?

Yes

No

Type

Manual wheelchair

Motorized wheelchair

Scooter

Sight Impaired

No impairment

Need glasses

Blind

Hearing Impaired

No impairment

Hearing aid

Deaf

Check all items that apply

Use Oxygen

Use respirator

Cognitive Impairment

Alzheimer/dementia

Development disability

Mental Health condition

Evacuation Transportation Requirement

Do you require transportation?

Yes

No

If yes

Standard Transportation

Yes

No

Can you slide transfer?

Yes

No

Do you need a vehicle with a lift

Yes

No

Must be transported by ambulance?

Yes

No

The following information will be helpful for your possible stay at an Emergency Shelter

Personal Emergency Kit?

Yes

No

Medication list?

Yes

No

File/Vial of Life?

Yes

No

Food Allergies?

Yes

No

If yes,specify

Other Allergies?

Yes

No

If yes, specify

Dialysis required?

Yes

No

If yes,specify how often

This form was filled out by

Self

Family Member

Other

Preparer

Certification

I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

Date

Month

Day

Year

Leave this field blank

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Cranbury Township

Middlesex County, NJ
23-A North Main Street
Cranbury, New Jersey 08512
PH: 609-395-0900 FAX: 609-395-8861

Town Hall Hours
Monday - Friday: 8:00am - 4:00pm

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