2. 
4. Registration for S.N.A.P.P. (Special Needs Aurora Police Program)

   If you have a family member with special needs, or you yourself have any special needs, please complete this form in its entirety. The Aurora Police Department will submit this information into a database which 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 pertinent 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 Yourself
7. If you are registering for someone other than yourself, please use the:
   Snapp Family Member Registration Form
9. First Name*
10. Middle Name*
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 Jersey New MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennessee TexasUtah VermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
18. Zip Code*
20. Gender*

    1. Male
    2. Female
21. Race / Ethnicity*
22. Height*
23. Weight*
25. Physical Description*
    (eyes/hair/scars/marks/tattoos)
27. Identified Disabilities*
31. Emergency Contact Information - Primary
33. First Name*
34. Last Name*
36. Street Address*
38. City*
39. 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
40. Zip Code*
42. Phone*
43. Relationship*
47. Emergency Contact Information - Secondary
49. First Name
50. Last Name
52. Street Address
54. City
55. 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
56. Zip Code
58. Phone
59. Relationship
63. Triggers, Strategies, and Known Places
    Please indicate information that is important for the Aurora Police to know about you, including but not limited to special identifiers such as a bracelet noting your disability, verbal/nonverbal, triggers, calming strategies, etc.
65. Please list any medical needs:*
67. Triggers to avoid, if possible:*
69. Strategies and/or needs for positive intervention:*
71. Name/address/phone number of any additional caretakers this individual may regularly visit in Aurora:
73. Do you wear an ID bracelet or alert band?*

    1. Yes
    2. No
74. Do you wear an ID necklace?*

    1. Yes
    2. No
75. Do you carry a special needs ID card?*

    1. Yes
    2. No
77. Are you verbal or nonverbal?*

    1. Verbal
    2. Nonverbal
78. Do you have an oxygen container?*

    1. Yes, at home
    2. Yes, at work or school
    3. No
79. Preferred Language*
80. Sensory issues?*

    1. Yes
    2. No
82. 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: *
84. 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
86. If “yes” is circled, please describe your environmental safety concerns:
88. Individual's place of employment or educational facility, including address:
90. Favorite places to visit: *
    (parks, etc.)
92. Have you been missing before?*

    1. Yes
    2. No
93. If yes, where were you located and when?*
95. Any other information you think may be important for first responders to know:
99. Relationship to Individual
101. Are you filling out this form on behalf of someone?

     1. Yes
     2. No
102. Relationship*
106. Photo
108. Is a current photo available to police?

     1. Yes
     2. No
109. Please upload a current photo of yourself.
111. Photos can also be emailed to SNAPP. Please include your name, date of birth, and address when submitting a photo.
     
     This information will be kept on file for a period not to exceed two (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, change in address, etc., needs to be made, please complete a new form along with an updated release and submit to the Aurora Police Department.
115. Release
     I represent that I, the individual identified below, am of legal age 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 me. I, therefore, 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 me. 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 or potential emergency which may involve me. I acknowledge that by providing this information for the purpose stated above that I am 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 myself, 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 I may have against those police, fire and emergency response agencies who may respond to an emergency or potential emergency involving me. I further acknowledge that by providing this information, no relationship nor duty, including but not limited to any contractual or agency or special relationship or duty, is established between me and against those police, fire and emergency response agencies who may respond to an emergency or potential emergency involving me and that the aforementioned police, fire and emergency response agencies do not waive or limit any defense of immunity available to them by law.
117. eSignature
119. First Name*
120. Last Name*
122. Email*
123. Date*
     Date
125. 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:


127. Submit

* indicates a required field