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Please input the personal information of the special needs individual.
Please input the personal information of a Parent and/or Guardian.
Please input the personal information of the special needs individual .
(Examples include sensory issues, certain behaviors, physical aggression, calming strategies, trigger mechanisms, audio or visual aids, or previous dealings with police.)
(Examples include words, pictures, electronic devices, etc.)
Please carefully read this information and print all pages for an in-person submission. This form may also be emailed to Lake Mary Police Department Community Relations.
I acknowledge and fully understand:
For participation in this Special Needs registry, I, individually or on behalf of the registered person, as applicable, hereby waive, release, discharge, and hold harmless the City from and against all claims, losses, damages, personal injuries (including but not limited to death), or liability (including reasonable attorney's fees), which directly or indirectly arise out of or result from any act or failure to act based on information received through the voluntary Special Needs Registry or which relates to the dissemination of information received through the voluntary Special Needs Registry.
I represent by signing below that the information provided is truthful, and that I am authorized to submit it on my own behalf or as the parent or legal guardian with authority to submit it on behalf of another.
This field is not part of the form submission.
* indicates a required field