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Functional Needs Database Form
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City of Surprise Functional Needs Database Information Form
The Functional Needs Database Information Form 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.
First Name:
*
Last Name:
*
Telephone:
*
Alternate Telephone:
Email:
*
Address1:
*
Address2:
City:
*
State:
Zip Code:
*
Neighborhood:
Emergency Contact Name:
*
Emergency Contact Phone:
*
Residence Key Holder:
Residence Key Holder Phone:
Needs: (check all that apply)
Wheelchair/Scooter Dependent
Non-ambulatory
Hard-of-Hearing or Deaf
Dementia or Alzheimer's
Utilizes service animal
Confined to Bed
Developmentally Disabled
Blind or Visually Impaired
Life sustaining machine used
Other needs (specify below)
Other Needs: (please specify)
If you previously entered this information with any other public safety organization in Maricopa County, please write the address below.
Would you like this information shared with the Police Department?
Yes
No
Other Comments:
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