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City of Surprise Functional Needs Database Information Form (#701)

This is a voluntary registry for Surprise residents to assist public safety personnel in identifying persons with disabilities or functional needs. This database will be used by the Surprise Public Safety Departments during disasters to determine where persons with disabilities or other functional needs reside. The information provided on this form will only be used by emergency personnel in the course of their duties.
This question requires a valid email address.
Needs: (check all that apply)
Would you like this information shared with the Police Department?