Special Needs & Homebound Registry Form

Town of Waterford, NY

65 Broad St.
Waterford, NY 12188

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Resources

2025 Town of Waterford Adopted Budget
Tax Collection
Dragon Boat Festival
Elections
Join Our Email List
Document Center
Town Code
Events Calendar
Employment Opportunities
Official Holidays
Area Links
Contact Directory
2016 Town of Waterford Comprehensive Plan
Special Needs & Homebound Registry Form
2022 Sewer Assessment Roll

Join Our Email List

Click to join our mailing list

Registration Request Form for Special Needs & Homebound Registry

The Town of Waterford is looking to compile a list of Special Needs & Home Bound residents in the Town & Village of Waterford

Fields marked with * are required.

Name *

Home Address *

Home Phone *

Cell Phone

E-mail

Mailing Address (If different)

Date of birth *

Sex *

Male Female

Residence Type

Private Home Apartment/ Condo Mobile Home Retirement Home Other

Describe other

Are you a year-round resident

Yes No

If no, From

Check all that apply

Mobility Impairment Major Respiratory Illness Receive services from County mental Health Center Receive service coordination from an agency servicing individual with developmental disabilities

Other

Name of Registrant

Name Caregiver or Contact

Relationship to registrant (if any)

Must check box to continue. *

I understand my participation in this registry is voluntary and all information maintained will be strictly confidential.