MI-SNAP Registration Form
Michigan Special Needs Awareness Program Registration
Information About Special Needs Person: First Name *
Your answer
Information About Special Needs Person: Last Name *
Your answer
Information About Special Needs Person: Nickname
Your answer
Information About Special Needs Person: Street Address *
Your answer
Information About Special Needs Person: City in Michigan *
Your answer
Information About Special Needs Person: Zip Code *
Your answer
Information About Special Needs Person: Phone Number (area code first) *
Your answer
Information About Special Needs Person: Date of Birth *
Your answer
Information About Special Needs Person: Height (in feet and inches) *
Your answer
Information About Special Needs Person: Approximate weight *
Your answer
Information About Special Needs Person: Brief description of disability or special need *
Your answer
Information About Special Needs Person: Is this person verbal or non-verbal? *
Are you filling out this form for yourself? *
If you're filling this out for someone other than yourself, what is your relationship to the special needs person?
Your answer
If you're filling this out for someone other than yourself, what is your first name?
Your answer
If you're filling this out for someone other than yourself, what is your last name?
Your answer
If you're filling this out for someone other than yourself, you will be listed as an emergency contact. Please enter your phone number with area code: *
Your answer
Please enter your email address *
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First name of one additional emergency contact *
Your answer
Last name of one additional emergency contact *
Your answer
Phone number of one additional emergency contact *
Your answer
How many MI-SNAP stickers do you need to place on your home and automobiles (maximum 5)? *
Your answer
I understand that the information provided to MI-SNAP and Mimi's Mission through this program is only meant as information for first responders. I understand it should not be considered a guarantee of safety nor the only emergency plan for a special needs person. I also understand that neither Mimi's Mission nor the participating emergency response departments will sell the information provided within this form. *
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