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2. The Special Needs Program is provided to enhance service to members of our community and ensure vital information is available to public safety and emergency responders.

   Information will remain confidential and only be used by emergency response agancies.
4. The following information is required to enroll in the City of New Braunfels Special Needs Program:
   
6. Please check one of the following:

   1. New Enrollment
   2. Changed or Updated Information
8. Name:*
10. Date of Birth:
11. Gender:*
    -- Select One --MaleFemale
12. Height:
13. Weight:
15. Address:*
17. Subdivision:
19. Gate Code:
21. Email Address:
23. Home Phone:*
24. Work Phone:
25. Cell Phone:
27. Emergency Contact Name:*
29. Home Phone:*
30. Work Phone:
31. Cell Phone:
33. Remarks or special information:
35. Please indicate Special Need(s), examples may include:
37. Check any that apply:

    1. Hearing Impaired
    2. Sight Impaired
    3. Bedridden
    4. Wheelchair Bound
    5. Require Oxygen
    6. Unfriendly Pets
    7. Mentally Impaired
    8. Non-English Speaking Individuals
    9. Alzheimer Patient
    10. Enrolled in Alzheimer's Association Safe Return Program
39. Other Unique Circumstances:
41. If applicable, please answer the following in the event of an evacuation order:
43. Check any that apply:

    1. Unable to drive and/or has no transportation.
    2. Special health needs that require assistance prior to transportation.
45. By checking below I indicate that I understand the above and authorize the New Braunfels 9-1-1 Emergency Communications Division to add the information provided to their computer files for use in the event of an emergency. Once enrolled, it is very important that the information be updated as required.
47. Check if applicable:*

    1. I understand.
Leave This Blank:


48. Submit

* indicates a required field