Blue Arrow Special Needs Registry Homepage 

Allegheny County Emergency Services
Special Needs Registry Form

If this is the first time you're providing information to Allegheny County EmergencyServices:
Please complete the form below.

If you're making changes to a form that was previously submitted, please do NOT submit a new form.  Instead: 

Email the changes to Email to: ; or
Phone the office during the hours of 8:30 AM to 4:30 PM, Monday through Friday, at
          412-473-1000 (Voice Only)
          412-473-3056 (TTY/TDD Only); or
Mail changes/corrections in writing to
          Emergency Services
          Attn: Special Needs Registry
          400 North Lexington Street, Suite 200
          Pittsburgh, PA 15208-2521


 

Applicant Information 

* Denotes required fields 

First Name: *   
Last Name: *   
Middle Initial:  
Suffix:
(e.g., Jr., Sr., III)
 

   Physical Address 
Street Address: *    
Apartment No. (if applicable): *    
City/Township/Borough: *
(where you pay taxes)
  
Note:  This should be the name of the municipality you live in, NOT what is listed in your mailing address. 
State: *    
Zip Code: *    
Primary Phone No.:   
Note:  This should be the phone number you answer most often.  This information may be used to contact you in
an emergency and may be included in a automated alert notification system.
 

  Do you have a TTY/TDD? * 
      
If "YES", is the above Phone Number for your TTY/TDD?
      
Email address:  
Confirm email address:  
Primary Language:  
Do you have a service animal?:* 
   
Provide description of service animal and include any special instructions:  
   


 

Condition / Mobility 

Please check ALL that apply which best describes your needs.
Please provide an explanation of what type of assistance is needed for each box that is checked.
Do you need any assistance hearing people? * 
   
If yes, what assistance do you need?   
Do you have a visual impairment? * 
   
If yes, what assistance do you need?  
Do you need assistance communicating with people? * 
   
If yes, what assistance do you need?   
Do you need assistance understanding or
remembering instructions or directions? * 
   
If yes, what assistance do you need?   
Do you have problems getting around without help? * 
   
I have a   
What additional assistance do you need?   
Is there anything further about your disability or condition
that you would like first responders to know? 
 
Do you use Voice Carry Over (VCO): * 
   
Do you use Hearing Carry Over (HCO): * 
   


 

Emergency Contacts  

  Primary Contact:   
First Name: *     
Last Name: *     
Relationship to Applicant: *      
Home Phone No.: *     
Work Phone No.: *     
Cell Phone No.: *     
Do you require interpretation service for Emergency Responders? * 
   
If yes, please list a name or service to contact in an emergency:   
Please provide a phone number for that person or service:  

Form Completion  

Is the person completing this form the Applicant? * 
   

If "NO", please provide the following for the person completing this form:
Name (first, middle, last):  
Address:  
City / Township / Borough:  
State:  
Zip Code:  
Phone Number:  
Relationship to Applicant:  


 

Acknowledgement 

The information that I have provided is true and accurate to the best of my knowledge, and I am submitting this application voluntarily. I understand that my contact information may be provided to local, county, state, and federal agencies for the purpose of emergency planning and emergency response. I understand that my acceptance to the Special Needs Registry does not guarantee assistance in evacuation or sheltering.

I authorize emergency personnel to enter my home, if necessary, to assist me and ensure my safety and welfare during an emergency.

 
Applicant Name:   OR  Person authorized to
submit this application: