Special Needs Address Alert Request Kanawha County Metro 911Special Needs Address Alert Request Name of individual Date of Birth: Sex FemaleMale Race African AmericanAmerican Indian or Alaska NativeAsianHispanicNative Hawaiian or Other Pacific IslanderWhite Height Weight Hair Color Eye Color Street Address Apt./Lot City/Town within Kanawha County Please provide the information that you would like given to First Responders in the event of an emergency call at their residence. Please add if they’re non-verbal, sensitive to sounds/lights/textures, run from first responders, severe (anaphylaxis) allergies, etc. Please Check: New Renew Change Requestor Information: Name Of Requestor Phone Number Of Requestor Address (if different than above) Apt./lot City State Relationship to individual Emergency Contact Information: Name Of Emergency Contact Phone Address Apt./lot City State Relationship to individual I wish to have the above address flagged in Metro 911’s Computer Aided Dispatch system to notify responders in the event of an emergency call at the above residence. Signature Date:
