Online Vulnerable Person Registry Form First Name * Last Name * Date of Birth * Gender * Male Female Other Prefer Not To Say Civic Address * Mailing Address * Primary Phone Number * Secondary Phone Number Email * What is the primary language spoken in your home * - Select One - English French Other Vulnerable Impairments of Applicant (Check all that apply) Vision Mental Health Cognitive (eg. Alzheimers) Deaf or Hard of Hearing Developmental / Intellectual (eg. Downs Syndrome) Mobility If your impairment is not listed above, please describe. Critical Medical Equipment (Check all that apply) Ventilator Insulin Oxygen Dialysis Do you require any critical medication? If so, please describe. Do you have any other critical equipment? If yes, please explain. In the event of an evacuation: * I require additional mobility support (e.g. wheelchair, walker, stretcher) I require electricity support for life-sustaining equipment I require electricity to remain safe in my home (shelter in place) I require the aid of a service animal I live alone I do not have family suppport locally How long can you take care of yourself in a large-scale emergency? Less than 6 hours 6-12 hours 12-24 hours 1-2 days 2-3 days 3+ days In the event of an evacuation (Please check all that apply) I am NOT able to exit my home without assistance I AM able to exit my home independently I have someone to help me if I require extra assistance in an emergency I need assistance in an emergency Does somebody in your home have access to a vehicle that can be used in case of an emergency evacuation? Yes No If assistance in evacuating is required, what information would be important to the responder assisting you? 4 wheel drive is required Use side access Use rear access Use front access Dangerous animals Is your property commonly known by a particular name? if yes, please describe. Is there any additional information you can provide that would be helpful? Primary Emergency Contact Information. If you do not have an emergency contact, please write 'No Emergency Contact' * Include: name, address, phone, email and relationship to you Secondary Emergency Contact Information (include name, address, phone, email and relationship to you) Include: name, address, phone, email and relationship to you Is there any further information that you think may be important for emergency responders to know about so that they can better support you in the event of an emergency? I agree with the Consent Statment * By typing my name below, I agree to allow the District of Sparwood to provide the information I have included in my Vulnerable Persons Registry (VPR) application to the local fire, police, paramedics and any other emergency responders for use in emergency situations. The information that I have provided is up to date and accurate. I understand that I still need to call 9-1-1 in the event of an emergency and that I am responsible for having my own emergency preparedness plan in place. I agree that my participation in the VPR is a completely voluntary sharing of information in the best interest of my safety. I understand that I am free to withdraw at any time without any given reason. While this VPR is created to help mitigate the risk of harm in the event of an emergency, it does not guarantee safety or protection. I declare that I am 18 years of age or older and that I have the authority to provide this personal information on behalf of the Registrant. I further declare that I have read the information provided and I consent to the collection, use and disclosure of this personal information. I agree to the Privacy Statement * By typing my name below, I understands and agree to the Privacy Statement below. The District of Sparwood ensures measures are taken to protect your information so that only those who require access will be able to do so. The data will remain secured and only used for the purpose it was collected. Should an emergency event occur, your information will be provided to authorized emergency responders to support your needs during an emergency. For more information the District of Sparwood Confidentiality and Privacy Policy can be found at www.sparwood.ca. Leave Blank This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
