Form Center

CONTACT INFORMATION

SNIP Registration
The Special Needs Information Program (SNIP) is designed to help emergency responders identify and respond to vulnerable residents with special needs. This is a voluntary program in which special needs community members of any age, or their family members, submit information like triggers, special accommodations, emergency contacts, and a photograph.
Please fill out this form to the best of your ability and attach at least one photograph.
If you need assistance filling out this form please call the Hanover Communications Center at 603-643-2222.
Please select which situation applies to you:*
1. I am completing this form for myself.
2. I am completing this form on behalf of another person.
Your Name
Your Email Address
Your Relationship to the Registrant
Your Address
City
State
Zip Code
Best Contact Phone Number
Fax Number (if any)
Registrant Contact Information
LEGAL FIRST NAME*
MIDDLE NAME(S)
LEGAL LAST NAME*
PREFERRED NAME
If you would like us to call you by a different name than your legal name.
DATE OF BIRTH*
DATE OF BIRTH
GENDER EXPRESSION*
1. MALE
2. FEMALE
3. NON-BINARY
4. PREFER TO SELF-DESCRIBE
SELF-DESCRIBED GENDER EXPRESSION
BEST PHONE NUMBER*
THIS IS A:*
1. LANDLINE
2. MOBILE
ALTERNATE PHONE NUMBER
THIS IS A:
1. LANDLINE
2. MOBILE
PREFERRED EMAIL ADDRESS
HOME ADDRESS*
TOWN*
STATE*
OTHER ADDRESS
WORK, SCHOOL, OR OTHER FREQUENTED LOCATION
TOWN
STATE
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HEIGHT*
FEET AND INCHES
WEIGHT*
POUNDS
EYE COLOR*
HAIR COLOR*
Please List Any Scars, Tattoos, or Other Identifying Marks
Other Identifying Information (Jewelry, Medical ID Card, Medical Alert Bracelet, etc...)
Please Attach A Current Photo*
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BRIEFLY DESCRIBE YOUR TOP THREE DE-ESCALATION STRATEGIES
BRIEFLY DESCRIBE "LIKES" THAT ARE FUN TO TALK ABOUT AND ENJOYABLE
BRIEFLY DESCRIBE "DISLIKES" THAT ARE ANNOYING OR FRUSTRATING TO TALK ABOUT
DO YOU USE ANY NON-VERBAL COMMUNICATION TECHNIQUES? (Written, Sign Language, Communication Technology, Etc...)
CAN YOU DESCRIBE SPECIAL PHRASES, SONGS, OR WORDS THAT YOU RESPOND WELL TO?
PLEASE SHARE ANY OTHER INFORMATION YOU THINK WOULD BE HELPFUL
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CONTACT #1 NAME*
RELATIONSHIP*
CONTACT #1 ADDRESS*
CONTACT #1 BEST PHONE NUMBER*
CONTACT #1 ALTERNATE NUMBER
CONTACT #2 NAME*
RELATIONSHIP*
CONTACT #2 ADDRESS*
CONTACT #2 BEST PHONE NUMBER*
CONTACT #2 ALTERNATE NUMBER
Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
By signing here I give permission for the staff of SNSC to share and exchange information in this form with the staffs of the Hanover, Hartford, and Lebanon dispatch centers and their First Responders for the purpose of providing assistance to me, or in the case of a minor or adult in guardianship, the person that I am registering.
1. I agree.
Electronic Signature*

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