Functional Needs Information Form

2. City of Surprise Functional Needs Database Information Form (#701)
   This is a voluntary registry for Surprise residents to assist public safety personnel in identifying persons with disabilities or functional needs. This database will be used by the Surprise Public Safety Departments during disasters to determine where persons with disabilities or other functional needs reside. The information provided on this form will only be used by emergency personnel in the course of their duties.

   This is a voluntary registry for Surprise residents to assist public safety personnel in identifying persons with disabilities or functional needs. This database will be used by the Surprise Public Safety Departments during disasters to determine where persons with disabilities or other functional needs reside. The information provided on this form will only be used by emergency personnel in the course of their duties.

4. First Name:*

5. Last Name:*

7. Telephone:*

8. Alternate Telephone:

9. Email:*

11. Address1:*

13. Address2:

15. City:*

16. State:

17. Zip Code:*

19. Neighborhood:

21. Emergency Contact Name:*

22. Emergency Contact Phone:*

24. Residence Key Holder:

25. Residence Key Holder Phone:

27. Needs: (check all that apply)

    1. Wheelchair/Scooter Dependent
    2. Non-ambulatory
    3. Hard-of-Hearing or Deaf
    4. Dementia or Alzheimer's
    5. Utilizes service animal

    1. Confined to Bed
    2. Developmentally Disabled
    3. Blind or Visually Impaired
    4. Life sustaining machine used
    5. Other needs (specify below)

29. Other Needs: (please specify)

31. If you previously entered this information with any other public safety organization in Maricopa County, please write the address below.

33. Would you like this information shared with the Police Department?

    1. Yes
    2. No

35. Other Comments:

Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field