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Special Needs Form
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Submitter Information
First Name
*
Last Name
*
Phone Number
*
Describe the person at this address who has special needs
First Name
*
Last Name
*
Current Age
*
Address
*
City
*
State
*
Zip Code
*
Medical Condition(s)
Hard of Hearing
Mobility Issues
Memory Concerns
Deaf/Deafened
Non-Verbal
Speech Impaired
Sensitivities
Lights
Sounds
Other
If checked other, explain
Attach a picture to help with identification
NOTE: This is only if you live within the city limits of North Myrtle Beach. This information will remain on file with NMBPD for one (1) year.
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