Logan's Law Registry Application

Please complete all required fields. Information submitted is encrypted and stored securely. Only authorized law enforcement personnel may access profiles.

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

Section 1 — Personal Information about individual with Special Needs

First Name *

Last Name *

Nickname *

Date of Birth *

Gender *

Address *

Phone *

Employer / School *

Photo

Optional. JPEG, PNG, GIF, or WebP — max 5 MB.

Section 2 — Physical Description

Race / Ethnicity *

Hair Color *

Eye Color *

Height (e.g. 5'10") *

Weight (lbs) *

Section 3 — Medical & Behavioral Information

Special Condition(s) *

Medications *

How does this medication affect actions, response, senses, the potential for violence, etc.? *

List any activations or triggers which may escalate an encounter. What actions should be avoided, if possible by first responders? *

List suggestions and techniques that can be taken to resolve a confrontation successfully. (interests, calming conversation, etc.) *

Familiar or favorite locations they frequent or enjoying visiting *

Primary form of communication *

This person is: *

Sensitive to light

Sensitive to touch

Likely to hide

Likely to fight

Subject to seizures

Afraid of Police or uniformed personnel

Violent

Section 4 — Emergency Contacts

Contact 1

Name *

Relationship *

Address *

Phone *

Name

Relationship

Address

Phone

Name

Relationship

Address

Phone

Name

Relationship

Address

Phone

Name

Relationship

Address

Phone

Section 5 — Person Submitting This Application

Your Full Name *

Your Relationship to Applicant *

Your Email *

Your Phone *

Your Address *

Section 6 — Certification & Signature

By typing your full name below you certify that the information provided is true and accurate to the best of your knowledge, and you consent to its use by authorized law enforcement personnel in accordance with Logan's Law.

Electronic Signature (type your full name) *