Personal Information

Medical Information

Emergency Contact Information

Emergency Transportation

By submitting this form, I/legal guardian agree that my name be added to the Pennington County Specific Needs Registry. I give Pennington County Emergency Management authorization to share this information with other community emergency responders in the event of an emergency in order to facilitate an effective response. I grant emergency responders permission to enter my home following an emergency event or disaster situation, if necessary, to assure my safety and welfare.