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4. 
5. City of Westland 911 Disability Awareness Registry

   The City of Westland Police Department 911 Disability Awareness Registry is used to help in identifying and assisting residents with disabilities and their families.

   
   

7. Is this a New Form or a Renewal?*

   1. New
   2. Renewal
9. Your Email*
11. Information for the Person with the Disability
13. Type of Disability
    -- Select One --AutismDowns SyndromeAlzheimer'sOther
14. Specific Diagnosis
16. Last Name of Person with Disability
17. Middle Name of Person with Disability
18. First Name of Person with Disability
20. Nickname (if any)
22. Gender
    -- Select One --MaleFemaleOther
23. Race
    -- Select One --WhiteAfrican American or BlackAmerican Indian or Alaska NativeAsian Native Hawaiian or Pacific IslanderOther
25. Date of Birth (please use MM/DD/YYYY format)
27. Street Address
29. City
30. State
31. Zip Code
33. Home Phone Number (include area code)
34. Cell Phone Number (include area code)
36. Language Spoken / Non-Verbal
37. Method of Communication
39. Identification Worn?

    1. Yes
    2. No
41. Upload Photo (if available)
42. Date of Photo (if attached)
44. GPS Tracking Device Worn?

    1. Yes
    2. No
45. GPS Tracking Website
47. Height (in feet and inches e.g. 5'7")
48. Complexion
49. Build
    -- Select One --Very ThinThinMediumHeavyVery Heavy
51. Hair Color
52. Hair Style
54. Facial Hair
    -- Select One --NoneMoustacheBeardBeard and Moustache
55. Eye Color
    -- Select One --BlueBrownGreenGrayHazel
57. Marks/Scars/Tattoos (include location on body)
59. Employer/School
60. Employer/School Address
62. Employer/School Phone
64. Remarks regarding Employer/School
66. Emergency Contact Information
68. Emergency Contact Name
69. Relationship to Person with Disability
71. Emergency Contact Address (if different than person's address)
73. Emergency Contact Phone Number
74. Emergency Contact Work Phone
75. Emergency Contact Cell Phone
77. More Information About the Person with the Disability
79. Inclination for Wandering or Things They are Attracted to:
81. Favorite Attractions / Locations Person Might be Found:
83. Best Methods to Approach (please include de-escalation techniques)
85. Life Threatening Medical Concerns:
87. What Not To Do: (include physical information, direct eye contact, loud noises, bright lights, etc.)
89. Other Relevant Information:
91. Authorization Agreement

    In the event of an emergency or disaster I hereby authorize the exchange of information between the Westland Police Department, Westland Fire Department and any public safety organization which the Westland Police Department seeks assistance from during the emergency situation. This is a volunteer program and any information provided can be rescinded by notifying the Westland Police Department at specialneeds@wlpd.net.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
93. Electronic Signature
Leave This Blank:


95. 1. Receive an email copy of this form.
96. Email address

    This field is not part of the form submission.

97. Submit

* indicates a required field