La Verne PD Logo
2061 THIRD STREET
LA VERNE, CA 91750

BUSINESS LINE 909.596.1913
NON-EMERGENCY DISPATCH 909.593.2531
EMERGENCY 911

La Verne PD Logo

2061 THIRD STREET
LA VERNE, CA 91750

BUSINESS LINE 909.596.1913
NON-EMERGENCY DISPATCH 909.593.2531
EMERGENCY 911

Special Needs Registry Application

Special Needs Registry Application

APPLICATION TYPE

Application Type

BASIC INFORMATION

CONTACT INFORMATION

Address
Address
Alternate Address
Alternate Address

DESCRIPTION / CHARACTERISTICS

Race
Complexion
Has
Wears

MEDICAL INFORMATION

Please indicate the nature of the special need(s) and any medical condition(s) that may apply:

PHOTOS OF PERSON BEING REGISTERED

Maximum file size: 10MB

Maximum file size: 10MB

CAREGIVER CONTACT INFORMATION

CONTACT INFORMATION

Primary Contact Address
Primary Contact Address

ADDITIONAL CONTACT

CONTACT INFORMATION

Additional Contact Address
Additional Contact Address

ADDITIONAL DETAILS

Do they tend to wander off... ?

OTHER INFORMATION

RELEASE

I, the undersigned, for myself and the registrant named above do hereby authorize the La Verne Police Department to release the aforementioned information in response to Emergency Calls (includes Missing Person incidents) regarding the registrant and do further agree to indemnify and hold harmless the La Verne Police Department and persons (placed) associated with it.

By checking this box and typing my name below, I am agreeing to the terms and conditions and am electronically signing my application.