Charlotte Fire Department
Special Population Database Registration Form

Please enter your information below.

Thank you for Registering !!!    This data is kept private.

Be sure to click the "Send" button at the bottom. 

If you have any questions or comments please call: 704-336-2441

NAME:

ADDRESS:  

Male or Female:

Phone:

Nature and severity of impairment:

Is this a new listing or an update?     New     Update   Unknown

Are there Oxygen tanks located in the residence?    Yes   No

Location of sleeping Area: