Register Ready NJ- Special Needs Registry

Human Services Division

Please fill out the following information as completely as possible. Should you have any questions, or need assistance in filling out this form, please feel free to call (856) 935-7510 Ext. 8304. All information will be kept strictly private and confidential.

Why register? This allows residents with disabilities or functional needs (as well as their families, friends, caregivers and associates) an opportunity to provide emergency response agencies with information that might prove crucial during a disaster, evacuation or other emergency.


Who is filling out this form?

Information about the person requiring assistance

Emergency contact information

Please provide as much contact information as possible.

Information about individual's condition or situation

This is to provide medical or emergency personnel with any information that may be vital to know in case of an urgent situation.
Must choose at least one option:
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