2. Special Needs Alert Program (S.N.A.P.)

   The Special Needs Alert Program (SNAP) is designed to ensure the safety of those residents of the City of Woodland that are most vulnerable to emergencies and disasters, the elderly and infirmed and those with various disabilities and special needs. The information you provide about health and medical conditions may be shared with Police, Fire and other emergency responders to assist them in responding to an emergency or disaster.

4. Alert Options*

   1. New Alert
   2. Updated Alert
5. Upload Image of Registrant
   Please make sure the photograph is only of the registering person (portraits are best). The photograph needs to be of clear quality, recent and preferably in color.
7. Email Address for Annual Update Alert*
   This email address will be used for annual update alert reminders.
9. Registrant Information
11. First Name*
12. Middle Name
13. Last Name*
15. Physical Address*
17. City*
18. State
19. Zip Code
21. Home Phone Number*
22. Cell Phone Number
24. Primary Language Spoken*
25. Date of Birth*
    Date of Birth
27. Gender*
    -- Select One --MaleFemale
28. Name of School or Work
30. Emergency Contact Information
32. First Name*
33. Middle Name
34. Last Name*
36. Physical Address*
38. City
39. State
40. Zip Code
42. Home Phone Number
43. Cell Phone Number*
45. Work Phone Number
46. Email Address*
48. Relationship to Registrant*
50. Special Needs*

    Please select all that apply:

    1. Visually Impaired
    2. Legally Blind
    3. Hearing Impaired
    4. Deaf
    5. Immobile
    6. Non-Verbal

    1. Seizure Disorder
    2. Speech Impaired
    3. Prosthesis
    4. Cerebral Palsy
    5. Down's Syndrome
    6. Muscular Dystrophy

    1. Cognitively / Developmentally delayed
    2. Mood Disorder / Mental Illness
    3. Paralysis (full or part)
    4. Parkinson's
    5. Alzheimer's / Dementia
    6. Autism Spectrum Disorder
52. Other / Additional Comments:
54. Special Considerations*

    Please check all that apply:

    1. Responds to verbal commands
    2. Communication / Speech Delay
    3. Communicates with PECS
    4. Communicates with Sign Language
    5. Scared of fast movements / crowds
    6. Responds well to touch

    1. Light / Siren Sensitivity
    2. Sound Sensitivity
    3. Uses Hearing Aids
    4. Colo Sensitivity
    5. Has high pain tolerance

    1. Uses Oxygen
    2. Wheelchair / walker/ cane
    3. Tendency to wander
    4. Fascination with water
    5. Tendency to Hide (*If yes, please provide more information in the comment section below)
56. Other / Additional Comments:
58. Disclaimer*

    You may revoke your consent to sharing information at any time by written request to: The Woodland Police Department, 1000 Lincoln Ave., Woodland, CA 95695 (ATTN: SNAP). "Providing this information does not insure that emergency responders will be able to provide services to you in an emergency but will assist them in responding appropriately based on available resources." Additionally, I give local law enforcement and/or medical personnel permission to enter my home in case of an emergency. By submitting this information, you consent to sharing information on this form. I certify that the information provided on this form is true and correct. It is my responsibility to update the information on this form as needed.

    1. I agree
60. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. 4) You are an authorized representative of the individual being registered and/or have the registrant's consent to submit this form on their behalf.

    1. I agree.
62. Electronic Signature*
63. Today's Date*
    Today's Date
64. Relationship *
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field