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2. 
4. Vulnerable Population Registry for Blaine County, Idaho

6. Blaine County Sheriff's Vulnerable Population Registry is a service to aid those who are a part of a vulnerable population, such as those who suffer from dementia, Alzheimer's Disease, Autism, or other special needs living in Blaine County, Idaho. 

   The registry provides vital information to police, fire, and paramedics to address the specific needs of the people on the registry if there is a call for service. The information can help first responders to provide the assistance needed and return the vulnerable individual home in a timely safe manner. 

   To help us, please complete as much information as possible.  You must be a family member to add someone to the database. Non-family members can request special permission. All registrations are approved by Chief Deputy Fruehling. The registry is voluntary and confidential. Information will only be shared with other Blaine County first responder agencies if there is a call for service. 

   If you have any questions regarding the Vulnerable Population Registry, please send an email to sheriff@co.blaine.id.us    

   We will get back to you as soon as possible.

10. Patient Information
12. Patient's First Name*
13. Patient's Middle Name*
14. Patient's Last Name*
16. Date of Birth
    Date of Birth
17. Age*

    Approximate if Unknown

18. Nickname
20. Patient's Street Address*
22. City*
23. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
24. Zip Code
26. Patient's Primary Phone Number*

    (XXX)XXX-XXXX

27. Patient's Cell Phone Number

    (XXX)XXX-XXXX

29. Patient's Diagnosis*
31. Additional Diagnosis
33. Medicinal Requirements

    Such as insulin, requires daily meds, oxygen, etc.

35. Additional Medical Information
37. Height

    Approximate if Unknown

38. Weight

    Approximate if Unknown

39. Race
    -- Select One --CaucasianHispanicBlack/African AmericanAsianAmerican Indian/Alaskan IndianPacific Islander/Native HawaiianMixed RaceUnknown/Other
41. Gender
    -- Select One --MaleFemaleOther
42. Hair Color
    -- Select One --BrownBlackBlondRedGrayBald
43. Eye Color
    -- Select One --BlackBrownBlueGreenHazelGrayOther/Unknown
44. Glasses

    1. Yes
    2. No
46. Scars, Identifying Marks, Tattoos, etc.
48. Valid Drivers License

    1. Yes
    2. No
    3. Unknown
49. Issuing Drivers License State
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouri MontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWest VirginiaWisconsinWyomingOther/Unknown
50. Drivers License/Identification Card #
54. Other Special Information
56. Living Status*
    -- Select One --Alonewith Spousewith Familywith CaregiverCare FacilityHomelessOther/Unknown
57. Primary Language*
59. Communication Method

    (Verbal, Non-Verbal, Hearing Difficulties, Picture/Assisted Communication Devices, Sign Language, etc.)

61. Wandering Tendencies

    (Places they like to go, things they are drawn to, or where they have gone in the past, etc.)

63. Safe Topics for Registered Person

    (Catchphrases or words the person likes to use or repeat. Topics the registered person enjoys talking about.)

65. Does the registered person fear the police?*

    1. Yes
    2. No
    3. Unknown
67. Does the registered person fear fire-fighters or paramedics?*

    1. Yes
    2. No
    3. Unknown
69. In some circumstances having access to weapons can pose a danger to the vulnerable person and/or to the first responders attempting to assist this individual. Does the registered person have access to weapons?*

    1. Yes
    2. No
    3. Unknown
    4. I am not comfortable answering this question.
71. Are there any known techniques that successfully deescalate the registered person?
73. Does the registered person have any triggers?
75. Is there anything that helps to calm the registered person?
79. Vehicle Information
81. Does the registered person have a vehicle?

    1. Yes
    2. No
    3. Unknown
83. Vehicle Make
84. Vehicle Model
85. Year
87. Vehicle Color
88. Vehicle Plate State
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
89. Vehicle Plate Number
93. School and Employment Information
95. School Name
96. Grade Level
97. School Phone Number
99. Employer Business Name
100. Employer Contact Name
101. Employer Phone Number
103. Employer Address
105. City
106. State
     -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWest VirginiaWisconsinWyoming
107. Zip Code
111. Primary Contact Information

     You must be a family member to add someone to the registry. Non-family members such as physicians, caregivers, or those with legal guardianship can request special permission. 

113. Primary Contact First Name*
114. Primary Contact Middle Name*
115. Primary Contact Last Name*
117. Primary Contact Phone Number*

     (XXX)XXX-XXXX

118. Alternate Phone Number

     (XXX)XXX-XXXX

119. Primary Contact Date of Birth
     Primary Contact Date of Birth

     Primary Contact Date of Birth
121. Primary Contact Email*
122. Relationship to Registered Person*
124. Primary Contact Street Address*
126. City*
127. State*
     -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
128. Zip Code*
132. Secondary Contact
134. Secondary Contact First Name
135. Secondary Contact Middle Name
136. Secondary Contact Last Name
138. Secondary Contact Phone Number
139. Alternate Phone Number
140. Secondary Contact DOB
142. Secondary Contact Email
143. Relationship to Registered Person
145. Secondary Contact Street Address
147. City
148. State
     -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
149. Zip Code
151. Attachments

     Attach identifiers such as pictures of the individual, their vehicle, or tattoos, etc.

153. Acknowledgment

     The undersigned certifies that (s)he is the person they claim to be and has filled in this Vulnerable Population Registry application truthfully and to the best of his/her knowledge. Knowingly providing false information may be subject to criminal prosecution. The undersigned grants permission to the Blaine County Sheriff Office, Blaine County Emergency Communications, or another designated Blaine County first responder agency to use the information provided to assist the registered vulnerable person without legal penalty.  All information will be kept confidential.

155. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that:

     1) Your application will not be signed in the sense of a traditional paper document;

     2) By signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature; 

     3) You may still be required to provide a traditional signature at a later date;

     4) You must agree with the above acknowledgment to submit this registration application.

     1. I agree.
157. Electronic Signature*
158. Date
Leave This Blank:


160. 1. Receive an email copy of this form.
161. Email address

     This field is not part of the form submission.

162. Submit Submit and Print

* indicates a required field