Elgin County, St. Thomas, and Aylmer Emergency Services offer special assistance to residents with disabilities when an emergency occurs. Should you or a resident in your household require special assistance and would like to have your name and address placed on our Registry, please complete this form and return it to us. This will ensure in the event of an emergency situation, the responders are better equipped to assist you. This voluntary registry will provide the Police Services with emergency contact information, detailed physical descriptions, known routines and special needs of this individual. This information will assist officers in communicating with, attending a residence of, or dealing with an emergency involving this individual.

As the Parent/Guardian/Administrator/Substitute Decision Maker, or self-advocate, you will be requested to complete information regarding the individual you are registering.

Please have a recent photo of the person you are registering (alone, not a group picture) as a hardcopy and a .jpg attachment to the registration form.

The registry information must be updated every year.

A hard copy can be downloaded at the link below:
Vulnerable Persons Registry Application


Vulnerable Person

New RegistrationUpdate
(for updates please include the name, DOB and then only new information)

Please upload photo:

Surname:
Given name:
Nickname/Alias:
Gender:
Date of Birth:

Residential Address

Street Address: Unit/Apt:
City: Township:
Postal Code: Phone Number:
Cell Phone Number: Email:

Living Arrangements: AloneWith FamilyFacilityOther

Employment/Educational Address

Employer/School:

Street Address:

City: Province: Postal Code:

Phone Number: Ext. #:

Transportation

Motor Vehicle Access: YesNo

Vehicle License Plate Number:

Type of Vehicle: Colour:

Registered Owner of Vehicle:

Driver's License Number:

Family Physician

Name: Phone Number:

Street Address: Unit/Suite:

City: Province:

Vulnerable Needs of Applicant

Please Check all that apply:
Mental HealthDevelopment/Intellectual (eg. Austism, Down Syndrome)Cognitive (eg. Alzheimer, Dementia)VisionMobilityLife Sustaining EquipmentYouth at RiskOther
If Other, please specify:

Physical Characteristics

Height: Weight: Build:
Complexion: Hair Colour: Hair Style:
Facial Hair: Facial Hair Color:
Eye Colour: Left Eye: Right Eye:
Hearing Device: Glasses/Contact:
Ethnic Background:

Communicates: verballynon-verbally Method to Communicate:

Languages Spoken: Preferred:

Mobility Aid:

Teeth (Dentures/Braces/Missing Teeth):

Heath Concerns:

Marks/Scars/Tattoos/Piercings/Amputations (Location/Description):

Does the individual wear or carry any identification on them:

Does the individual have a history of wandering: yesno

Does the individual have an inclination to wander of leave to a specific area and/or favourite attraction? (ie. previous addresses, previous employment, stores, etc. Please list all that apply):

Does the individual have a set daily routine? - walks, appointments, visits coffee shop etc.?

What is the best method of approaching this individual? Please include de-escalation (calming) techniques if required:

CONTACTS

Please be aware that the individuals listed may be contacted in the event of an emergency.

First Contact

Name: Relationship:
Street Address: Unit/Apt:
City: Province:
Phone Number: Cell Number:
Email address:

Second Contact

Name: Relationship:
Street Address: Unit/Apt:
City: Province:
Phone Number: Cell Number:
Email address:

Third Contact

Name: Relationship:
Street Address: Unit/Apt:
City: Province:
Phone Number: Cell Number:
Email address:

CONSENT TO COLLECT, USE AND DISCLOSE PERSONAL INFORMATION'

This form must be completed by the vulnerable person or their Legal Guardian

Questions about this collection should be forwarded to the:
* Aylmer Police - 20 Beech Street East, Aylmer, ON NSH 3H6 519-773-3146
* Elgin County Ontario Provincial Police - 42696 John Wise Line, St Thomas, ON NSP 3S9 519-631-2920
* St.Thomas Police-45 Caso Crossing, Saint Thomas, ON NSR 0G7 519-631-1224

The information collected in this form is personal information (including but not limited to name, contac:. information, physical and behavioural characteristics and traits) as defined by the Municipal Freedom of
Information and Protection of Privacy Act, R.S.O.1990, c M.56. It is your responsibility to ensure that the 4nformation so collected is current and valid.
Purpose for Collection & Use: The personal information is collected in accordance with the Police Service Act, R.S.O. 1990, c P.15, for the purpose of responding to incidents of missing persons, and to assist with Police interaction with the Registrants where incidents may occur. Occasionally, the Police may refer to the personal information to better understand the Registrants' needs and how we can improve service in relation to the Registrant.
Disclosure: The personal information collected may be disclosed to other law enforcement and emergency services bodies for the purpose described above.
Retention: The retention, as well as any other use or disclosure, of this information will be dictated by the requirements under the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c M56
Release: In consideration of the Police compliance with the collection. use and disclosure as set out aoovz release, waive and forever discharge the Police Services Board, its employees and agents. and other ta\A enforcement bodies from all claims, demands, damages, costs, expenses, actions, causes of action, whether m law or eauity, resulting or alleged to result from your compliance with the foregoing authorization. I further waive anv and all rights I may now or in the future have with respect to any disclosure of the personal information collected.
I agree that this is a completely voluntary sharing of information in the best interest of safety for the vulnerable person. This is to mitigate risk of harm but in no way guarantees safety or protects the individual from being accountable for criminal activity.
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 above and I consent to the collection, use and disclosure of the personal information as described and the release described.

Registration form completed by:
Date of Birth:
Relationship to Registrant:
Street Address: Unit/Apt:
City: Province:
Phone Number: Cell Number:
Email Address:

I hereby declare that the information provided in this document is true and correct to the best of my knowledge and that I consent to the collection, use and disclosure of this personal information.

Agree

Date:



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