The information provided by you will be kept confidential and used only to provide City of Bloomington Emergency Responders with the information needed to deal with situations or emergencies involving a Special Needs person.

The notification expires 2 (two) years after the date it was submitted. You may update or renew it at anytime by filing a new form.

The information provided will be entered into databases maintained by the Bloomington Dispatch Center and may be shared with other police, fire or EMS agencies as needed to provide services to the individual.

The individual must understand that the information provided here will not result in any type of preferential treatment to the individual and that the City of Bloomington, it’s police and fire departments nor any other responding agencies will not be held liable for duties relating to the reporting of special needs individuals.

I also understand that if any of the provided information changes, I must notify the City of Bloomington by filing an amended request form. The information will self expire 2 (two) years from the date received by the City of Bloomington and I must renew the form prior to the expiration date if I want the information kept in the Bloomington Dispatch databases.

A Special Needs Individual is hereby defined as:  Having a physical or mental impairment, or has or is at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also requires health and related services of a type or amount beyond that required by individuals generally.