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SPECIAL NEEDS REGISTRY
Romeoville Fire Department
Description:
Residents or businesses who have special medical or other needs (important medications, medical devices, or other requirements) are encouraged to fill out the Registry form. Businesses who also have special needs may complete this form. This form will be submitted to the Village of Romeoville so that emergency responders will know ahead of time about any special circumstances that may be encountered when responding to a call at your home or business. The information will remain confidential and be used only by fire, police, and 9-1-1 personnel that serve your area.
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Name of Individual/Business:
Individual's Date of Birth:
Address:
Phone Number:
Please indicate which category the individual fits in:
1. Person with Special Needs
2. Business
3. Medical
Please indicate the type of need is required either by the resident or business:
1. Unobstructed Route/Exits
2. Water Needs
1. Electrical Needs
2. Medical Needs
Please upload any supporting documents you want to share that may be helpful to emergency responders.
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Please indicate your relationship to the senior or person with the special needs:
1. Spouse
2. Parent
1. Guardian
2. Self
Your Name:
Your Phone:
Additional Contact Name:
Additional Contact Phone:
Special Need/Medical History:
Medications:
Physician's Name:
Physician's Phone:
Physician's Affiliate Hospital:
Hospital Phone:
If you have medical equipment requiring uninterrupted electrical power, call ComEd at 1-800-334-7661 to be placed on their list.

Because of my special medical needs, I hereby give my permission for my name, telephone number and the nature of my medical condition to be released to the fire and law enforcement agencies responding to my home. I understand this information will remain confidential and used only by fire, police and 9-1-1 personnel that serve my area. I understand that I must renew this form on an annual basis to prevent automatic removal from the file The undersigned understands and agrees that this form is for informational purposes only and shall not be construed under any circumstances to create any special duty or relationship of any kind between the undersigned and the Village of Romeoville to provide fire, police, or emergency services beyond those afforded to the general public.
Spouse/Parent/Guardian Signature:
Date
Date
Important Numbers:
24-hour Emergency: 911
24 hour Police Non-Emergency: 815-886-7219
Fire Department Non-Emergency: 815-886-7227
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