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Special Needs Information Program Form

  1. Register for Special Needs Program
    Parents of autistic children and families of loved ones living with mental health or medical disabilities are invited to join the Lebanon Police Department’s Special Needs Information Program (SNIP), a program to help emergency responders identify and respond to vulnerable residents with special needs. Please complete the following form to register for our Special Needs Information Program.

    For more information about this program, please visit our Special Needs Information Program page or contact us by phone at 603-448-8880 or by email at police@lebanonnh.gov.
  2. LPD Patch Blue Transparent
  3. Individual's Information
  4. Physical Description
  5. Gender
  6. Medical Information
  7. Diagnosis and Medical Description
    Check all that apply:
  8. Will emergency lights and siren trigger behaviors?
  9. Behavior Traits
  10. Verbal?
  11. Fight/Flight?
  12. Responds to Name?
  13. Eye Contact?
  14. Delayed Speech?
  15. Impaired Sense of Danger?
  16. Responds to Verbal Commands?
  17. Repetitive Behavior?
  18. Emergency Contact Information
  19. Agreement
    By signing here, I give permission for the staff of SNSC to share and exchange information in this form with the staff of other local Police Departments for the purpose of providing assistance to me, or in case of a minor or adult in guardianship, the person that I am registering.
  20. Leave This Blank: