Disability Registration

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Phone Number

Phone Service Provider

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please check approved designations for inclusion in the 9-1-1 Database to assist public safety dispatchers in responding to an emergency at your address: Any changes should be communicated to your 9-1-1 Municipal Coordinator promptly.

Check All that apply to indicate someone at the address:

“LSS” Lie Support System: has equipment required to sustain their life.

“MI” Mobility Impaired: is bedridden, wheelchair user or has another mobility impairment.

“B” Blind: is legally blind.

“DHH” Deaf or Hard of Hearing: is deaf or hard of hearing.

“TTY”: communication via the phone may be by TTY.

“SI” Speech Impaired: has a speech impairment.

“CI” Cognitively Impaired: is cognitively impaired.

PLEASE REMOVE any designation presently on file.

PLEASE CHANGE existing designators to those shown above.

Notice

By initiating this document I understand that I am responsible for notifying my 9-1-1 Municipal Coordinator of any changes with regard to the status of the above disability indicator(s). I further agree, I will indemnify, defend and hold the State 911 Department, GDIT, my public safety dispatch location and municipality harmless from and against any claims, suits and proceedings (including attorney fees associated therewith) resulting from or arising out of the initial provision or updating of this information.

Name*

Full Name

Date*

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Please check approved designations for inclusion in the 9-1-1 Database to assist public safety dispatchers in responding to an emergency at your address: Any changes should be communicated to your 9-1-1 Municipal Coordinator promptly.

Notice

Plymouth Police Department