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2. 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.
3. 
5. Individual's Information
7. Individual's Full Name
9. Preferred Name
10. Date of Birth
11. Age
13. Address
15. City
16. State
17. Zip Code
21. Physical Description
23. Gender

    1. Male
    2. Female
24. Scars or other identifying marks?
26. Height
27. Weight
28. Eye Color
29. Hair Color
31. Photo
35. Medical Information
37. Diagnosis and Medical Description

    Check all that apply:

    1. Autism Spectrum Disorder
    2. Downs Syndrome
    3. Cerebral Palsy
    4. TBI
    5. PTSD
    6. Mental Health Disorder
    7. Deaf

    1. Visually Impaired
    2. Hearing Impaired
    3. Prone to Seizures
    4. Asthma
    5. Cognitive Impairment
    6. Other
39. If other, please describe:
41. Will emergency lights and siren trigger behaviors?

    1. Yes
    2. No
45. Behavior Traits
47. Verbal?

    1. Yes (verbal)
    2. No (non-verbal)
48. Fight/Flight?

    1. Fight
    2. Flight
49. Responds to Name?

    1. Yes
    2. No
51. Eye Contact?

    1. Yes
    2. No
52. Delayed Speech?

    1. Yes
    2. No
53. Impaired Sense of Danger?

    1. Yes
    2. No
55. Responds to Verbal Commands?

    1. Yes
    2. No
56. Repetitive Behavior?

    1. Yes
    2. No
58. Repetitive Behavior
60. Response to Person in Uniform
62. Sensory Issues?
64. Likes?
66. Dislikes?
68. Nonverbal Cues?
70. Verbal Cues?
72. Other Identification Information?
74. Any other additional information?
78. Emergency Contact Information
80. Name of Emergency Contact #1
82. Address
84. City
85. State
86. Zip Code
88. Home Phone
89. Work Phone
90. Cell Phone
94. Name of Emergency Contact #2
96. Address
98. City
99. State
100. Zip Code
102. Home Phone
103. Work Phone
104. Cell Phone
106. 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.
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108. Submit

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