2. 
4. Family Member Registration for S.N.A.P.P. (Special Needs Aurora Police Program)
   If you have a family member with special needs, please complete this form in its entirety. The Aurora Police Department will submit this information into a database that will assist with how to appropriately interact with this individual if the need arises. Due to the range of needs for those with disabilities, it is important to indicate specific triggers that may be harmful as well as specific ways to interact successfully.
   
   If you have questions about the Special Needs Aurora Police Program, email Detective Jennifer Hillgoth, Aurora Police Department, or call her at 630-256-5554.
6. About Individual with Special Needs
7. If you are registering yourself, please use the:
   SNAPP Self Registration Form.
9. First Name*
10. Middle*
11. Last Name*
13. Date of Birth*
    Date of Birth
14. Street Address*
16. City*
17. State*
    -- Select One --AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
18. Zip Code*
20. Gender*
21. Race / Ethnicity*
23. Height*
24. Weight*
26. Physical Description*
28. Identified Disabilities*
32. Emergency Contact Information - Primary
34. First Name*
35. Last Name*
37. Street Address*
39. City*
40. State*
    -- Select One --AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPeurto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
41. Zip Code*
43. Phone*
44. Relationship*
48. Emergency Contact Information - Secondary
50. First Name
51. Last Name
53. Street Address
55. City
56. State
    -- Select One --AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPeurto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
57. Zip Code
59. Phone
60. Relationship
64. Individual's place of employment or educational facility, including address:
66. Name/address/phone number of any additional caretakers this individual may regularly visit in Aurora:
70. Triggers, Strategies, and Known Places
    Please indicate information that is important for the Aurora Police to know about this individual, including but not limited to special identifiers such as a bracelet noting their disability, verbal/nonverbal, triggers, calming strategies, etc.
72. Please list any medical needs:*
74. Triggers to avoid, if possible:*
76. Strategies and/or needs for positive intervention:*
78. Do you have any environmental safety concerns such as pets, stored weapons, access to medications or other potential hazards you would like first responders to be aware of? *

    1. Yes
    2. No
80. If “yes” is circled, please describe your environmental safety concerns:
82. Does the individual wear an ID bracelet or alert band?*

    1. Yes
    2. No
83. Does the individual wear an ID necklace?*

    1. Yes
    2. No
85. Does the individual carry a special needs ID card?*

    1. Yes
    2. No
86. Is the individual verbal or nonverbal?*

    1. Verbal
    2. Nonverbal
88. Does the individual have an oxygen container?*

    1. Yes, at home
    2. Yes, at work or school
    3. No
89. Preferred Language*
90. Does the individual have any Sensory Issues?*

    1. Yes
    2. No
92. If “yes” is circled above for sensory issues, please describe the sensory issues and provide any suggestions for first responders to best approach and handle in a crisis situation:
94. Has the registrant been missing before?*

    1. Yes
    2. No
95. If yes, where was he/she located and when?
97. Favorite places to visit: *
101. Relationship to Individual
103. Are you filling out this form on behalf of someone?*

     1. Yes
     2. No
104. Relationship to the individual:*
106. Your First Name*
     Name of individual completing this form?
107. Last Name*
108. Phone*
112. Photo
114. Is a current photo available to police?

     1. Yes
     2. No
115. Please upload a current photo of the individual:
117. Photos can also be emailed to [email protected]. Please include the individual's name, date of birth, and address when submitting a photo.
     
     This information will be kept on file for a period not to exceed 2 years. A notification will be made prior to that two year deadline. If the information is not confirmed at that time, the information will be removed from the database. If any change in guardianship, in address, or in any other information needs to be made, please complete a new form, including an updated release, and submit it to the Aurora Police Department.
121. Release
     I represent that I am of legal age and capacity and that I represent the above named Individual as the parent or legal guardian (copy of 'letter of office' attached as applicable) and acknowledge that the information provided herein has been given freely and voluntarily and accurately for the sole purpose of assisting police, fire and emergency response agencies to more effectively respond to an emergency or potential emergency which may involve the Individual. I, therefore, on behalf of the Individual, authorize the use of this information for that purpose in the discretion of those police, fire and emergency response agencies who may respond to an emergency or potential emergency involving the Individual. I agree to the dissemination of this information to any police, fire and emergency response agencies which may need access to this information in order to respond to an emergency which may involve the Individual. I acknowledge that by providing this information for the purpose stated above that the Individual is not entitled to any preferential treatment nor a more timely response to any emergency or potential emergency. I agree to keep this information current and acknowledge that the information provided becomes the property of the Aurora Police Department for the purpose stated above. I further for the Individual, his/her heirs, executors, administrators, personnel representatives and assigns, waive and release any and all rights, claims and causes of action arising from participation in SNAPP which they may have against those police, fire and emergency response agencies who may respond to an emergency or potential emergency involving the Individual. I further acknowledge that by providing this information, no relationship nor duty, including but not limited to and contractual agency or special relationship or duty, is established between the Individual and those police, fire and emergency response agencies involving the Individual and that the aforementioned police, fire and emergency response agencies do not waive or limit defense or immunity available to them by law.
123. eSignature
125. First Name*
126. Last Name*
128. Email*
129. Date*
     Date
131. Agreement

     1. I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.
Leave This Blank:


133. Submit

* indicates a required field