ALERTING 9-1-1 TO YOUR SPECIAL NEEDS
If you or your child has a special situation, medical condition or disability, you should alert the 9-1-1 Emergency Response System to that need now, before an emergency occurs. This will help to ensure that you will receive the appropriate emergency assistance in an event. To do this, you complete this form that identifies your needs and mail it to the address below. The information you submit will be put into the 9-1-1- system and remain there until your request that it be changed or removed or if your phone account is closed. Please update any changes to your information as they occur by completing another form. Please note: this service only works with wirelines (a phone that has a wire from a telephone pole to your home.) It is not available for cell or internet phones.
Telephone number (include area code)___________________________________________
Address (street, town,state, zip code)____________________________________________
Circle all the conditions that apply:
B-Blind Someone at this location is blind or visually impaired.
COG-Cognitive Impairment Someone at this location has a cognitive impairment.
H/D-Hard of Hearing/Deaf Someone at this location is hard of hearing or deaf.
LSS-Life Support System Someone residing at this location is physically linked to equipment
required to sustain his or her life.
MI-Mobility Impaired Someone residing at this location is bedridden, uses a wheelchair or
has a mobility impairment.
PI-Psychiatric Impairment Someone at this location has a psychiatric impairment.
SI-Speech Impairment Someone at this location has a speech impairment.
TDD-Telecommunications Device for the Deaf Someone at this location may be using a
TO MAKE CHANGES TO A PREVIOUSLY SUBMITTED FORM, CHECK ITEM BELOW:
_____ Please REMOVE any existing indicators presently on file with the 9-1-1 system.
_____Please CHANGE existing indicators to the ones identified above.
Read, sign and date:
By completing this form, I understand that I am responsible to notify SBC (9-1-1) of any changes with regard to the above information. I further agree that I will indemnify, defend and hold harmless SBC, the State of Connecticut, the Public Safety Answering Point, and my municipality from and against any and all claims, suits and proceedings resulting from or arising out of the provision of this information.
I understand that this information will remain as part of my 9-1-1 record until such time as I notify SBC to either change or delete it.
_______________________________ ________________________________ ___ ___________________
Signature Print Name Date
ENHANCED 9-1-1 DMS GROUP
310 ORANGE ST., 2ND FLOOR
NEW HAVEN, CT 06510