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Otsego County 9-1-1 Central Dispatch Authority Special Health Care Needs Form The Otsego County Central Dispatch Authority is working to better improve our service to you, and we need your help! You can provide us with additional information, specific to your location that will better the efficiency of emergency services in a time of need. Otsego County has adopted an address ordinance that requires you to have your address posted. For specific details on the county’s ordinance requirements, have your property tax code/identification number available and contact the following: Otsego County Equalization Department (989)731-7410 ALL INFORMATION THAT YOU PROVIDE IS CONFIDENTIAL Name of Special Needs Person: Telephone Number: Date of Birth: Street Address (No P.O. Boxes): Apt. No. City: Township: Zip Code: Nearest Cross Street or Additional Directions: This Address is a: Please Check One House Mobile Home Farm Business Rental Owner Occupied Apartment This Address: Please Check if Applicable Requires a “Buzz In” Entry Has a Residential Automatic/Intrusion Alarm Company Name: Key Holder Name and Telephone Number: PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM ---PAGE BREAK--- Please indicate in the appropriate any special condition(s) that exist at your location: Handicap Person Bedridden Person Watch Dog (or dangerous animal) On Oxygen Supply TDD User (Telecommunication Device for the Deaf) Day Care Provider Foster Care Home Alzheimer/Memory Impaired Hearing Impaired Speech Impaired Under Medical Care-Heart Problems Gun or Rifle Special Information: HAZARDOUS CHEMICALS Please Check All That Apply Gasoline Diesel Propane (LPG) Ammunition Explosives Pesticides Poisons Radioactive Materials Other: ADDITIONAL INFORMATION: This information will remain in our files for one year from date of entry. Please contact us to keep the information complete and up to date. RETURN THIS COMPLETED FORM TO: Otsego County Central Dispatch Authority Attn: Special Needs 225 W. Main St. – Suite 203 Gaylord, Michigan 49735