<form-template> <fields> <field type="checkbox-group" required="true" label="Please select one of the below: " class="checkbox-group" name="checkbox-group-1689095398423"> <option value="option-1" selected="true">I am applying to have my name added to the Vulnerable Person's Registry</option> <option value="option-2">I am registering someone I know for the Vulnerable Persons Registry. They have given me permission to add them. I am listed as the emergency contact. </option> </field> <field type="text" subtype="text" required="true" label="Full name (person to be added to the registry):" class="form-control text-input" name="text-1650309619254"></field> <field type="date" required="true" label="Date of Birth (person to be added to the registry):" class="form-control calendar" name="date-1650309631559"></field> <field type="text" subtype="text" required="true" label="Street Address (person to be added to the registry):" class="form-control text-input" name="text-1650309645035"></field> <field type="text" subtype="text" required="true" label="Phone Number (person to be added to the registry):" class="form-control text-input" name="text-1650309658965"></field> <field type="text" subtype="email" label="Your Email (person to be added to the registry):" class="form-control text-input" name="text-1650309681933"></field> <field type="checkbox-group" required="true" label="What vulnerabilities do you experience? Please select all that apply:" class="checkbox-group" name="checkbox-group-1650309805878"> <option value="Mobility Issues" selected="true">Mobility Issues</option> <option value="Visual Impairment">Visual Impairment</option> <option value="Hearing Impairment">Hearing Impairment</option> <option value="Development Disability">Development Disability</option> <option value="Cognitive Impairment">Cognitive Impairment</option> <option value="Challenges Related to Mental Health">Challenges Related to Mental Health</option> <option value="I require electricity for life sustaining equipment (life support, oxygen dialysis, etc)">I require electricity for life sustaining equipment (life support, oxygen dialysis, etc)</option> <option value="No access to internet/email">No access to internet/email</option> <option value="Other">Other</option> </field> <field type="textarea" label="If Other please specify:" class="form-control text-area" name="textarea-1650310026450"></field> <field type="textarea" label="Please provide additional information about the vulnerabilities you, or the person you are adding, experience:" class="form-control text-area" name="textarea-1650310047123"></field> <field type="select" required="true" label="Is home dialysis preformed in the home?" class="form-control select" name="select-1650310074589"> <option value="Select Option" selected="true">Select Option</option> <option value="Yes">Yes</option> <option value="No">No</option> </field> <field type="select" required="true" label="Do you own a pet?" class="form-control select" name="select-1650310183168"> <option value="Select Option" selected="true">Select Option</option> <option value="Yes">Yes</option> <option value="No">No</option> </field> <field type="text" subtype="text" label="If Yes, please specify what type of pet:" class="form-control text-input" name="text-1650310215442"></field> <field type="text" subtype="text" required="true" label="Emergency Contact Name:" class="form-control text-input" name="text-1650309696088"></field> <field type="text" subtype="text" required="true" label="Emergency contact phone number:" class="form-control text-input" name="text-1650309697348"></field> <field type="text" subtype="text" required="true" label="Emergency Contact relationship:" description="Parent, sibling, friend, etc" class="form-control text-input" name="text-1650309718116"></field> <field type="paragraph" subtype="output" label="I allow the Vulnerable Persons Registry Program of the Municipality of Jasper to provide the information I included in my Vulnerable Persons Registry (VPR) registration form to local Fire, Emergency Medical Services and Emergency Management for use during emergencies. I know that it is important for me to ensure that the VPR 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 I am also responsible for having an emergency plan in place in order to be prepared to remain safe for at least three days. I recognize that the VPR does not guarantee my safety, but provides an added safeguard where local emergency service groups will make every effort to increase the possibility of my safety during emergencies. I agree to release the Municipality of Jasper and its elected officials, employees and agents from and against all claims, demands, actions, suits, loss, damage, costs, charges and expenses (collectively “Claims”) which I may incur, suffer or be put to because VPR is unable to guarantee my safety or otherwise in connection with the VPR. I understand that if I am approved, my information will be available to authorized local emergency service groups. I also understand that I will be notified once my information will be made available to those authorized emergency service groups. I further understand that as part of the program, twelve-month updates are required and the Municipality of Jasper will contact me to complete an update; however, if unsuccessful the Municipality of Jasper will remove me from the VPR. I know that I can also request to be removed from the VPR at any time. Only the registrant or legal guardian is legally able to authorize the choice to register. By clicking 'Accept' below, you are authorizing that you agree to the above information and would like to register" class="paragraph"></field> <field type="checkbox" required="true" label="Accept Terms and conditions" class="checkbox" name="checkbox-1650310263197"></field> </fields> </form-template> Submit Submitting...
