Online Special Needs Registry Form

For information regarding this Special Needs Survey form, please go to the Special Needs Registry Page.

Special Needs Registry Submission

  • Submitting this form is NOT a guarantee that emergency services will be available to provide any special responses to the recorded address! It is important for all residents to make individual plans and preparations for their care and safety in an emergency.

    The Hempfield Township Emergency Management Agency (HEMA) is concerned for those persons in our community who may have special needs during emergency situations. As part of our planning process, we are attempting to obtain information about these individuals and families. Please complete and return the emergency special needs survey on the page below. This will allow specific departments and agencies to contact these persons to aid them in preparing for an emergency. The survey does not imply that Hempfield Township departments, personnel, and mutual-aid agencies will provide any special responses to the recorded address. Our goal is to assist those residents in making a pre-planned family emergency preparedness plan.

    In order to determine the special needs of Township residents during an emergency, please complete the questionnaire below. Information received through the Emergency Special Needs Survey, may be maintained in a confidential database in the Hempfield Township Emergency Operations Center. If you have any questions about this form please refer to the FAQ’s on the HEMA Website ( or contact HEMA at 724-834-7232 ext. 107.

  • Check the box beside those items which apply to you or anyone living in your home. Please mark ALL boxes that apply to any person who lives in your home.
  • If person filling out this form is different from person(s) requiring assistance: