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 the collection and use of this personal information, please contact the Access and Privacy Office at 902.943.2148 or privacy@halifax.ca.

I am completing this form as: *

the applicant

the legal representative/guardian of the applicant

an emergency contact of the applicant

Personal Information of Applicant

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 Homecare Services:

Yes

Please list the Home Care Services that are applicable:

Vulnerable Needs of Applicant

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., Alzheimer's disease)

Mental Health

Other…

Life Sustaining Equipment

Ventilator

Oxygen

Dialysis

Other…

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

I require electricity for life-sustaining equipment.

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

I do not receive 24-hour support at home.

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:

How long can you care for yourself in a large-scale emergency?

As a guide, think about your day-to-day activities.

Information Tips

Please provide any important additional information that will help first responders assist you during an emergency (e.g., I use a wheelchair).

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 #s (telephone call and/or text) and email address.

If I have included contact information for a representative/Legal Guardian and/or Primary/Secondary Emergency Contact in this application form, they will be contacted to confirm this role and to obtain their consent for the VVPR Coordinator to register them in the hfxALERT system so that they will receive the VVPR emergency alerts on my behalf.

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 within 45 days of receipt of my application. I also understand that I will be notified of the date on which my information will be made available to those authorized first responders. 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