Special Needs Assistance Form - Michigan City Fire Department

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Special Needs Assistance Form

Help us better serve you during emergencies by completing the Special Needs Assistance Form. Providing this information allows the Michigan City Fire Department to respond more effectively and ensure the safety of those with special needs. Fill out the form today to help us prepare for your unique needs in case of an emergency.

Step 1 of 3

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Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Date of Birth(Required)

MM slash DD slash YYYY

Sex(Required)

Male

Female

Height(Required)

Weight(Required)

Hair Color(Required)

Brown

Blonde

Red

Eye Color(Required)

Brown

Blue

Hazel

Green

Identifying Marks/Scars:

Primary Diagnosis/Disability:

Other Relevant Medical Condition/Behaviors in Addition to Primary Diagnosis/Disability (Check all that apply):

No Sense of Danger

Prone to Seizures

Blind

Deaf

Non-Verbal

Cognitive Impariment

Combative/Aggressive

Other

Explain:

Prescription Medications Needed, Sensory or Dietary Issues, If Any:

Method of Preferred Communication (Verbal: words, songs, etc. Non-Verbal: sign language, pictures, etc.):

Emergency Contact Name(Required)

First Last

Emergency Contact Phone number(Required)

Emergency Contact Address(Required)

Street Address City State ZIP Code

Consent(Required)

By checking this box, you agree that the information provided may be shared with emergency personnel, including:

Law Enforcement
Staff EMS
Fire Fighters
Dispatchers
First Responders
Medical Personnel

Join Our Team

Join the Michigan City Fire Department and become part of a dedicated team committed to protecting and serving the community. We’re looking for motivated individuals to help make a difference through courageous work and professional training.

Become A FirefighterBecome A Firefighter

(219) 873-1440(219) 873-1440

We are a dedicated team of highly trained professionals committed to safeguarding lives, property, and the community.

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Department Information

2510 East Michigan Boulevard
Michigan City, Indiana 46360
(219) 873-1440
(219) 873-1451

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