Special Needs Application for Emergency Services

The Bloomington/Monroe County Special Needs Registry for first responders is designed to help in emergency situations. It can be vitally important for a first responder (a police officer, a fire fighter or an emergency medical technician) to know that a resident at the address where help is needed is visually impaired, hearing impaired, mobility impaired or has other similar needs.

People who have disabilities that first responders might need to know about and who want to be included in this database may register here.

People also may print out a form from the web site, fill it out and mail it to the address on the form.

The form is available in alternative formats and in Spanish upon request. If you need help completing the form, you may call 349-3429 or e-mail human.rights@bloomington.in.gov.

Once your information is in the registry, when someone from your residence calls 911, dispatch employees will know immediately about your special needs and will be better able to provide appropriate services. Once you're registered, someone will contact you every six months to make sure that the information is still current and accurate and to update the information as necessary.

It's vital that you cooperate with the updating process to keep your name in the registry.

Connotes required fields

Household Information

Contact info for the person with the special need.

Medical Impairments
Primary Contact

This is the primary contact Emergency services should use during an emergency situation. Please describe the relationship of this person to the person with the disability. If this is the same person, please choose "same as above." You may leave this section blank. If this is a family member or other caretaker, please choose "other."

Secondary Contact

Please provide a second emergency contact in case the primary contact is unavailable.

Other Information/Additional Contacts
Submit