Submit a C.A.R.E. Alert

Personal / Family Representative

Representative Full Name(Required)

Representative Email(Required)

Representative Phone Number(Required)

Relationship To Person In Need(Required)

Do You Reside In The Same Household?(Required)

Yes

C.A.R.E Alert Individual

Image of Care Alert Individual(Required)

Accepted file types: jpg, pdf, png, jpeg, Max. file size: 256 MB.

(Solo Picture of Individual, Please Avoid Group Photos)

Care Alert Individual Full Name(Required)

Care Alert Individual's Address(Required)

Street Address Address Line 2 City State ZIP Code

Care Alert Individual's Phone Number(Required)

Alert Individual's Date of Birth

Race(s)

Gender

Weight

Height

Information

School / Work

Has The Individual Wandered Away Before?

Yes

If Vulnerable Person Operates A Vehicle

Triggers

Calming Methods

Does this person have a tracking device assigned to them?

Yes

And if so, whom has that information?

Tracker Address

Street Address Address Line 2 City State ZIP Code

Tracker Phone

Tracker Email

Brief Description of Special Needs

Treating Physician (If Known)

Physician Phone Number

Treating Counselor (If Known)

Counselor Phone Number

Anything Else We Should Know?

Emergency Contacts

Emergency Contact #1

Emergency Contact Phone Number #1

Emergency Contact #2

Emergency Contact Phone Number #2

Consent

I agree to the below statement.

Registrants understand that the information they provide through C.A.R.E.Alert may be accessed by law enforcement personnel, mental health professionals, and/or emergency responders in the course and scope of their duties and that such information may be shared and/or disseminated as determined by law enforcement personnel, mental health professionals, and/or emergency responders. By registering with C.A.R.E.Alert and submitting information through C.A.R.E.Alert, to the fullest extent permitted by applicable law, registrants waive their rights, if any, under applicable state and/or federal medical privacy laws, as to law enforcement personnel, mental health professional, and/or emergency responder’s use of such information in the course and scope of their duties. Registrants hereby release C.A.R.E.Alert, law enforcement personnel, mental health professionals, and/or emergency responders for the inadvertent disclosure of information that registrants submit through C.A.R.E.Alert.

By submitting the above C.A.R.E.Alert information I agree to the fullest extent permitted by law to release, discharge, indemnify, and hold harmless the Greece Police Department, and their respective officers, officials, employees, agents and volunteers (collectively “Indemnitees”) from and against all claims, liability, losses, costs, causes of actions, or demands (including attorney fees and costs) (“Losses”) that I, or anyone on my behalf, have or may have by reason of Indemnitees’ receipt, use, failure to use, or disclosure of the C.A.R.E.Alert information submitted, including injury, damage, or death. This duty to indemnify and hold harmless shall not apply to the extent such Losses are caused by the sole or active negligence or willful misconduct of the Indemnitees. I understand and agree that this waiver and release is to be binding on my heirs and assigns.

Registrants acknowledge that in registering with C.A.R.E.Alert, participating law enforcement agencies, mental health professionals, and/or emergency responders reserve the right to determine the appropriate response to any given call for assistance and/or situation and do not guarantee any specific course of action and/or outcome.

Registrants represent that the information they submit through C.A.R.E.Alert is true, correct, and accurate to the best of Registrant’s knowledge.