2. Person Registering Vulnerable Person

4. As the person registering a vulnerable person, please complete the following fields with as much detail as possible.

6. First Name*
7. Last Name*
9. Your Street Address, City, State, and Zip*
11. Phone Number*
12. Email Address
14. Relationship to Vulnerable Person*
16. Vulnerable Person's Information
18. SECTION 1. CONTACT INFORMATION
20. First Name*
21. Middle Name
22. Last Name*
24. What name does this person preferred to be called?*
26. Home Phone Number*
28. Street Address, City, State, and Zip
29. Living Arrangements

    1. Alone
    2. With family
    3. With roommates
    4. Institution
31. Are there any weapons at the residence? If yes, please explain in detail:
33. SECTION 2. IDENITFYING INFORMATION
35. Race*
    -- Select One --African AmericanAsianHispanicNative AmericanMiddle EasternPacific IslanderWhite
36. Gender*

    1. Female
    2. Male
    3. Transgender
37. Date of Birth*
38. Age*
40. Height*
41. Weight*
42. Eye Color*
43. Hair Color*
45. What items of clothing are commonly worn by the idividual?
47. Upload a Photo of Vulnerable Person (Should be passport quality)*
49. SECTION 3. MEDICAL INFORMATION
51. Dentures

    1. Upper
    2. Lower
    3. Both
    4. N/A
52. Hearing Aids

    1. Left
    2. Right
    3. N/A
53. Visual Aids

    1. Contacts
    2. Glasses
    3. N/A
55. Any visible identifying marks (amputations, deformities, scars, tattoos, etc.)
57. Diagnosis*
    -- Select One --Alzheimer's AspergersAttention Deficit/Hyperactivity DisorderAutismBlind/Low Vision/Vision ImpairmentCerebral PalsyDeaf/Hearing Loss/Low hearingDementiaDown SyndromeEpilepsy/SeizuresHuntington DiseaseIntellectual DisabilityMental IllnessOther Brain IllnessOther Developmental Disability Other Mental Disability Physical DisabilityPTSD
58. If other diagnosis, please explain:
59. Level of functionality*
    -- Select One --Low support requiredModerate cognitive declineModerate support requiredNo cognitive declineSevere cognitive declineSevere support required
61. SECTION 4. LOCATION INFORMATION
63. Is there a history of prior wandering?

    1. Yes
    2. No
64. Does the person have a GPS device?*

    1. Yes
    2. No
66. Previous and/or Favorite Locations and Places
68. SECTION 5. COMMUNICATION INFORMATION
70. Is the person verbal?*

    1. Yes
    2. No
71. Will the person respond to being called by their name?

    1. Yes
    2. No
73. Preferred Communication Mode*
74. Languages Spoken
76. Does the person have any prior law enforcement, military, or specialize training?

    1. Yes
    2. No
78. If yes, please explain in detail:
80. SECTION 6. BEHAVIOR AND TRIGGER INFORMATION
82. What is the best way for officers to approach the person?*
84. What type of behavior should officers expect? (Kicking, hitting, biting, stimming, self-harming, self-talking, etc.)*
86. Does the person respond negatively to bright lights, loud noises, or sirens?*

    1. Yes
    2. No
88. Does the person avoid or dislike eye contact?

    1. Yes
    2. No
90. Does the person respond negatively to touch?*

    1. Yes
    2. No
92. Have restraints been used on the person?*

    1. Yes
    2. No
94. Does the person respond negatively to animals?*

    1. Yes
    2. No
96. Please describe any triggers or sensitivities the person has*
98. What can calm or soothe the person?
100. Any favorite toys, topics of discussion, objects, music, likes or dislikes?
102. Any information as to what law enforcement SHOULD NOT do
104. SECTION 6. ANY OTHER INFORMATION
106. Any other information you would like to provide
108. Emergency Contact Information
110. First Name*
111. Last Name*
113. Emergency Contact Street Address, City, State, and Zip
115. Relationship to Vulnerable Person*
117. Phone Number*
118. Email Address
122. IMPORTANT - PLEASE READ BEFORE SUBMITTING FORM

     Please review the following before completing, and submitting this form.

     • Participation in this registry is VOLUNTARY.
     • The information on this form will be added to the San Mateo Police Department's record management system and may be distributed to first responders in order to better care for you or your family members.
     • We respect the right to privacy and will make every attempt to ensure that all personal information remains confidential, unless release of the information is required by law.
124. INFORMATION IS ACCURATE AND TRUTHFUL*

     I acknowledge that the information provided is accurate and truthful and submitted voluntarily for the purpose of assisting first responders in more effectively responding to a potential emergency involving the vulnerable person.

     1. I AGREE
126. USE AND SHARING OF INFORMATION*

     I consent to the use and sharing of this information for the above listed purposes.

     1. I AGREE
128. KEEPING INFORMATION UPDATED*

     I further acknowledge that it is my responsibility to update the information provided if there are changes.

     1. I AGREE
Leave This Blank:


130. 1. Receive an email copy of this form.
131. Email address

     This field is not part of the form submission.

132. Submit

* indicates a required field