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Exceptional Needs Registry Application

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Steps

  1. 1. Step One (current)
  2. 2. Massachusetts 9-1-1 Disability Indicator Form

  • Step One

    2. The Fire and Police Departments seek to serve all the residents of the community with the utmost respect and dignity. The Town of Hingham has created the Exceptional Needs Registry as a method to enable first responders who are called in to assist an individual with unique circumstances.

      This form combines the Massachusetts 911 Disability Indicator form with the Town of Hingham Exceptional Needs form. The information will remain confidential and will only be accessed if a call to 911 is generated by a telephone number associated with the person listed on the form with a disability.

      Disclaimer: By submitting this form, you acknowledge and understand that the information provided is not protected under the Health Insurance Portability and Accountability Act (HIPAA). There is no expectation of HIPAA compliance, and the data you share may not be handled in accordance with HIPAA standards.
    11. To which gender identity do you most identify? (Check all that apply)
    14. Please provide up to 3 Emergency Contact Name and Phone Number. This may be Doctors, Family, Friends.
    27. Description of Exceptional Resident
    37. Do you require an interpreter?
    38. Do you use TTY?
    53. Is there a history of Substance Abuse?
    54. Is there a history of Trauma?
    55. Is there a history of Domestic Violence?
    65. Transportation Information in event of emergency (check all that apply)