Public Safety Sticker Program

Public Safety Sticker Program

Application Form
The purpose of the Public Safety Sticker Program is to help first responders identify any special medical conditions and or circumstances when interacting with our citizens.

Once the form is completed, it will be reviewed by our first respnder agencies and a bumper/window sticker will be issued out to you. You will place the the bumper/window sticker on a visible section of the rear of your vehicle where first responders can clearly identify it. First responders will identify this sticker and be aware of your specific needs for care.

ELIGIBILITY REQUIREMENTS:

Be a resident of Pharr.

Have a medical condition as diagnosed by a Physician.

If you would like to participate please take a moment to fill out the form below. Parrticipation is completely voluntary.
PERSONAL INFORMATION
Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2 (Apartment #)

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Email
example@example.com
PROOF OF RESIDENCE

*MUST BE A RESIDENT OF PHARR TO BE ELIGIBLE
Proof of Residence Document*

This can be a Drivers License, Utility Bill, or Mail with your name
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MEDICAL / SPECIAL CONDITIONS
Select Medical Conditions:*

DeafDiabeticDisabledAutistic or Special NeedsAlzheimers or DementiaOther
Medical Condition / Special Condition Documentation*

Please upload documentation from a medical provider identifying they above listed conditions.
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VEHICLE INFORMATION
Total Number of Vehicles*
Only vehicles that you travel in on a regular basis are eligible.
Vehicle # 1*

License Plate Number

Street Address Line 2

CityState

Zip Code
Vehicle # 2*

License Plate Number

Street Address Line 2

CityState

Zip Code
Vehicle # 3*

License Plate Number

Street Address Line 2

CityState

Zip Code
Vehicle # 4*

License Plate Number

Street Address Line 2

CityState

Zip Code
Should be Empty:

Public Safety Sticker Program

PERSONAL INFORMATION

PROOF OF RESIDENCE

MEDICAL / SPECIAL CONDITIONS

VEHICLE INFORMATION