Utah Special Needs Registry

The information in this section MUST be for the person to be registered.

A 'Registrant' is the person who may need assistance.

First Name

Middle Name

Last Name

Address

City

Zip

County in Which Registrant Lives

Email of Registrant (or caregiver)

Sex

Age

Does the registrant live year round at this address ?

If NO, what is the secondary address? Provide the secondary address IF in Utah

CIty and ZipCode of secondary Utah residence

Primary Language Spoken:

Priority 1 Phone Number

Phone 1 Type

Phone 1 Textable?

Phone 2 Phone Number

Phone 2 Type

Phone 2 Textable?

Phone 3 Phone Number

Phone 3 Type

Phone 3 Textable?

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This Section is for the Alternate/Emergency Contacts

Alternate Contact 1 - Last Name , First

Relationship (Choose 1)

Alternate 1 Phone Number

Phone 1 Type

Alternate Contact 1 Email

Alternate Contact 2 - Last Name, First

Relationship (Choose 1)

Alternate 2 Phone Number

Phone 2 Type

Alternate Contact 2 Email

Additional Notes, Numbers, Contacts

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This section is for the person submitting information for the Special Needs Registrant

FIrst and Last Name of Submitter (If other than applicant)

Relationship to Registrant

Phone Number

Phone Type

Please Check ALL that apply to the Registrant:

Check all that apply:

Additional Info and Other Assistance Needs: EX: if dialysis needed, specify type (life-sustaining?)

Registrant Does Not Have: (Check all of the following as applicable)

Mobility: Registrant Has Difficulty Walking and Requires: (Check all of the following as applicable)

Service Animal is needed/used, please specify type of animal:

Medical Equipment Required for Registrant that is Not Easily Transportable: (Check all that apply)

Required Waiver of Liability

By checking the YES box below, I verify that I am the submitter of this registry information. I confirm that I have read the required waiver of liability form.

Waiver of Liability Form can be found here

I am the submitter, and this verifies consent of information

Name of Submitter