NOTICE: BY SUBMITTING THIS FORM YOU AFFIRM UNDER OATH THAT YOU ARE LEGALLY RESPONSIBLE FOR THE PERSON NAMED BELOW FOR WHOM YOU HAVE PROVIDED INFORMATION AND THAT YOU CONSENT TO HAVE THIS INFORMATION SHARED AMONG LAW ENFORCEMENT PERSONNEL FOR ENROLLMENT IN COLUMBIANA COUNTY’S SPECIAL NEEDS REGISTRY. PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS.
