Vulnerable Population Registry Application

Name:
Address:
Home Phone:
Cell Phone:
Application Date:
Date of Birth:
Place of Birth:
Sex:
Race:
Height:
Weight:
Hair Color:
Hair Length:
Dentures:
Eye Color:
Glasses:
Contacts:
Individual Traits:
Native Language:
Other Languages:
Speech Problem:
Allergies:
Physical Conditions / Disabilities:
Diagnosis:
Medications:
Are you completing this registration on someone's behalf? (If yes, relationship to applicant):

Medical and Behavior Questions

Are you an Insulin dependent Diabetic? Yes No
Heart Conditions? (be specific) Yes No
Do you have a Pacemaker? Yes No
Do you wear a Medical Alert Tag? Yes No
Do you have a VIAL/ or file of Life? Yes No
Are you already registered for a special needs shelter? Yes No
Do you have a pet in your home? Yes No
Do you have periods of confusion? Yes No
Do you require assistance walking? (cane, walker, etc.) Yes No
Do you wander frequently? Yes No
Mode of travel normally used?
Possible destinations when leaving home?
List Habits or Hobbies
Usual Type of Clothing
Daily Routine
Name person answers to
Phrase or words person responds to?
Previous Occupation
Are you physically or verbally abusive?

Doctor and Care Giver Information

Doctor Name:
Phone:
Address:

Doctor Name:
Phone:
Address:

Primary Care Giver
Name:
Date of Birth:
Address:
Home Phone:
Cell Phone:
Place of Business:
Business Address:

Secondary Care Giver
Name:
Date of Birth:
Address:
Home Phone:
Cell Phone:
Place of Business:
Business Address:

I hereby authorize the Lady Lake Police Department, it's officers, or other designated persons and employees to use this information in locating and returning the listed applicant to his/her residence should he/she become a lost/missing person or disoriented. I further authorize the Lady Lake Police Department to release the listed information in this or other related documents to other emergency agencies but then only on an "as needed" basis should it become necessary for them to assist in aiding the Vulnerable Registry person.

If registry for this individual becomes no longer necessary or if the listed information should change, I will notify the registering agency at the earliest possible moment. I understand that giving false information to a Law Enforcement Agency is a violation Florida State Statutes regarding the filing of false reports and I also understand that enrollment into this registry is a privilege not to be abused nor is it intended to deprive any individual from their right to privacy or freedom, but rather to assist the Vulnerable Population.

I acknowledge having read the above information. Furthermore, I fully understand and agree with its contents.

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Email:

By submitting this form I certify the information I provided is true and accurate to the best of my knowledge.