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Special Needs 911 Registry Form

  1. WLPD Badge
  2. City of Westland Special Needs 911 Registry

    The City of Westland Police Department Special Needs 911 Registry is used to help in identifying and assisting residents with disabilities and their families.


  3. Is this a New Form or a Renewal?*
  4. Information for the Person with the Disability
  5. Identification Worn?
  6. GPS Tracking Device Worn?
  7. Emergency Contact Information
  8. More Information About the Person with the Disability
  9. Authorization Agreement

    In the event of an emergency or disaster I hereby authorize the exchange of information between the Westland Police Department, Westland Fire Department and any public safety organization which the Westland Police Department seeks assistance from during the emergency situation. This is a volunteer program and any information provided can be rescinded by notifying the Westland Police Department at specialneeds@wlpd.net.

    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.

  10. Leave This Blank:

  11. This field is not part of the form submission.