Citizen Corps DuPage

Operation Helping Hand is a cooperative public safety program in DuPage County. It is designed to ensure the safety of those residents of DuPage County that are most vulnerable to emergencies and disasters, the elderly and infirmed and those with various disabilities. The information you provide about your health and medical condition may be shared with police, fire and other emergency workers to assist them in responding to a disaster or emergency. You may revoke your consent to sharing information at any time by sending a written request to DuPage County Office of Homeland Security and Emergency Management, 136 N. County Farm Road, Wheaton, IL 60187. Providing this information does not insure that you will receive special treatment, but your needs will be given consideration. By submitting this information, you consent to sharing the information on this form.

If you would rather print out and mail in the registration form Click Here to download a printable PDF.

Registrant Information

Prefix:

First Name:

Last Name:

Suffix:

House Number:		Street Direction		Street Name:		Street Type: (St., Dr., etc.)	Apt. #:
City:			State		Zip Code:
Closest Major Intersection:
Home Phone:	Cell Phone:
Email:

Gender:		Date of Birth:	(mm/dd/yyyy)
Primary Language Spoken:

Next of Kin or Person Responsible for Healthcare

Prefix:

First Name:

Last Name:

Suffix:

Address:
City:	State	Zip Code:
Home Phone:	Cell Phone Number:	Email:

Special Needs

Special Circumstance and Required Assistance (Check all that apply):

Special Circumstance	Required Assistance
I have a visual impairment	I need transportation
I have a hearing impairment	I need assistance with basic daily care
I have a mobility impairment
I have a service animal
I live alone
I have a pet
I have another disability (describe): NOTE: Please separate multiple items with a semicolon (;)

Special Needs / Equipment (Check all that apply):

Oxygen	Wheelchair, walker, cane
Ventilator / Respirator	IV Support
Dialysis	Other (list): NOTE: Please separate multiple items with a semicolon (;)

Information Provided By: Relationship to Registrant:

Information Entered By: Same as Provided By

You will be assigned a Registration number. Please record this number and the password you enter below so in the future you can update your profile when needed.

Password (10 characters or less):