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)___________________________________________ 

Name: ____________________________________________________________________

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

                                                                                 TDD/TTY.

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

MAIL TO:

SBC

ENHANCED 9-1-1 DMS GROUP

310 ORANGE ST., 2^ND FLOOR

NEW HAVEN, CT 06510