Voluntary Vulnerable Persons Registry

Collection and Use Statement

In accordance with Section 485 of the Municipal Government Act (MGA), any personal information collected on this form will be used only by municipal staff and, if necessary, individuals and/or organizations under service contract with the Halifax Regional Municipality for purposes relating to executing the Voluntary Vulnerable Persons Registry program.

If you have any questions about this form/survey, please call 311 or email contactus@311.halifax.ca

Are you a resident of the Halifax Regional Municipality?

Yes

I am a resident.

I am not a resident.

Halifax's Voluntary Vulnerable Persons Registry is only available to residents of the municipality.

I am completing this form as:

the applicant

a caregiver

Contact Information

First Name:

Last Name:

Age:

Gender:

Address:

Unit / Access Code:

City:

Postal Code:

Primary Phone #:

Secondary Phone #:

Is a TTY (Teletypewriter) used?

Email Address:

Confirm email

I receive Continuing Care or private homecare services (e.g., VON)

Yes

Please list the Continuing Care or private homecare services (e.g., VON) that are applicable:

Eligibility Criteria

Please check all that apply:

Vision

Deaf, Deafened or Hard of Hearing

Mobility

Bedridden

Developmental/Intellectual (e.g., Autism Spectrum Disorder, Down Syndrome)

Cognitive (e.g., dementia)

Mental Health

Other…

I require electricity for life-sustaining equipment.

Note: Please check this box if you use a CPAP/BiPAP machine, oxygen, or any other life-sustaining equipment that requires electricity.

I require electricity after ______ (minimum 6) hours to remain safe:

Life Sustaining Equipment

Ventilator

Oxygen

Dialysis

Other…

I do not receive 24-hour support at home.

Additional Information

I will not be able to exit my home by stairs.

I live alone.

I currently receive meals from Meals on Wheels.

Note: If selected, it will not guarantee meal assistance during large-scale emergencies.

I do not have family support locally.

I have trouble with speech or language (e.g., I use an ASL interpreter).

Please specify:

Information Tips

Please provide any important information that will help first responders to assist you during an emergency (e.g., I use an electric wheelchair that I cannot move manually by myself if the battery is not charged).

Do you have an Emergency Contact?

Yes

Primary Emergency Contact

First Name:

Last Name:

Relationship (Please check one of the following):

Spouse/Partner

Parent

Son/Daughter

Sibling

Relative

Friend

Other…

Primary Phone #:

Secondary Phone #:

Email:

Do you have a Secondary Emergency Contact?

Yes

Secondary Emergency Contact

First Name:

Last Name:

Relationship (Please check one of the following):

Spouse/Partner

Parent

Son/Daughter

Sibling

Relative

Friend

Other…

Primary Phone #:

Secondary Phone #:

Email:

Do you have a representative/Legal Guardian?

Yes

Representative/Legal Guardian

First Name:

Last Name:

Relationship (Please check one of the following):

Spouse/Partner

Parent

Son/Daughter

Sibling

Relative

Friend

Other…

Address:

Unit / Access Code:

City:

Postal Code:

Primary Phone #:

Secondary Phone #:

Email:

Select your preferred contact for your six-month updates. Please contact:

Applicant

Representative/Legal Guardian

Primary Emergency Contact

Choose one of the following update methods:

Phone

Mail

hfxALERT

I understand that if I am approved to be added to the VVPR, the VVPR Coordinator will register me in the hfxALERT system so that I will receive VVPR emergency alerts as needed. These alerts will be sent to me via all means of communication that I have provided, including Primary/Secondary Phone Numbers (telephone call and/or text) and email address.

Consent

Please read and sign below for your application to be reviewed:

I understand that the Halifax Regional Municipality will provide the information I included in my Voluntary Vulnerable Persons Registry (VVPR) registration form to local first responders for use during emergencies. I understand that if I rely on electricity for life-sustaining equipment such as oxygen, my information may also be provided to Emergency Management volunteers and service providers. I know that it is important for me to ensure that the VVPR program has accurate and up-to-date information at all times. I understand that I still need to call 9-1-1 in an emergency and am also responsible for having an emergency plan in place to be prepared to remain safe for at least three days. I recognize that the VVPR does not guarantee my safety but is an added safeguard where local emergency service groups will make every effort to increase the possibility of my safety during emergencies.

I understand that if I am approved, some of my information will be available to authorized local first responders and volunteers during the event of an emergency. I further understand that as part of the program, updates are required at a minimum of every 6 months using my preferred method or alternatives if required. I acknowledge that the VVPR Coordinator will make every effort over a two-month period to complete an update; however, if unsuccessful, the VVPR Coordinator can remove me from the VVPR, and I will be notified accordingly. I know that I can request to be removed from the VVPR at any time.

Signature of Applicant or representative/Legal Guardian

Sign above