Blue Envelope Program - Special Needs Registry

NOTICE: By submitting this form you affirm under oath that you are legally responsible for the person named below for whom you have provided information and that you consent to have this information shared among law enforcement personnel for enrollment in the Special-Needs Registry. Please keep a copy of this form for your records.

Please contact us annually to update the picture and if any information changes.

📸 Submit Your Completed Paper Application

Did you download or pick up a paper application? Take a photo of your completed form and submit it here. Your photos will be sent directly to our office.

Your Name (optional)

Your Email (optional)

Photo of Application (Page 1 or Front) Accepted formats: JPG, PNG, GIF

Photo of Application (Page 2 or Back) (optional) If your application has multiple pages, upload the second page here

Additional Notes (optional)

Printable Form

Printable Form (Creole) | Printable Form (Spanish)

Personal Information

Last Name

First Name

Middle Initial

Date of Birth

Gender

Height

Weight

Home Address

City

State

Zip Code

Contact Phone Number

Email Address

Primary Language

Build

Hair Color

Eye Color

Wears Glasses?

Yes No Glasses

Social Security Number

Driver's License / ID Number

State

Other Personal Characteristics (Tattoos, Piercings, Scars, Marks, etc.)

Disability Information

Disability

If "Other," please describe

Method of Communication

Verbal Non-Verbal Sign Language Written Speech Assistance Device

Comment re: communication

Vehicle Information

Type of Vehicle

License Plate

State

Emergency Contact Information - Primary

Last Name

First Name

Middle Initial

Address

City

Contact Phone Number

Email Address

Relationship to Registrant

Emergency Contact Information - Alternate

Last Name

First Name

Middle Initial

Address

City

Contact Phone Number

Email Address

Relationship to Registrant

Other Information for First Responders

Describe any of the registrant's life-threatening concerns (food or medical allergies / seizures / medications / etc.)

If the registrant uses an Epi-pen, please provide location where it is stored

Are there any triggers which affect the registrant? (loud noises / bright lights / etc.)

Are there any calming methods used for the registrant?

Does the registrant frequent or gravitate to any locations in particular? (water / playground / old house / etc.)

Please add any additional information you may think will be helpful for first responders to know regarding the registrant

Upload Picture of Registrant (optional)

Optional: Receive a copy of this form

Email address (this field is not part of the form submission)