Vulnerable Persons Registry

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Residents who may require special assistance are asked to complete the form below. Submission of the form will send your information to the Perth Fire Services and notify firefighters of extra assitance required during emergencies and natural disasters. Registration is completely voluntary.

Please provide the following information about the individual choosing to provide their information for the Perth Fire Services Vulnerable Persons Registry. This information will be kept confidential and only used as necessary to assist in an emergency situation.

Email *

Applicants first and last name *

Approximate age

YYYY

Gender

Female

Male

Prefer not to disclose

Other:

Clear selection

Address *

Postal Code *

Access code (door, gate, etc) if applicable. *

Primary telephone number. *

I receive Home Care Services. *

Yes

Other:

If yes, state the Home Care Services that are applicable:

Primary Emergency Contact full name. *

Relationship *

Parent

Spouse/Partner

Sibling

Relative

Son/daughter

Friend

Other:

Primary phone for emergency contact. *

Email address for primary contact.

Secondary Emergency contact full name if necessary.

Relationship

Parent

Spouse/Partner

Sibling

Relative

Son/daughter

Friend

Other:

Clear selection

Secondary emergency contact phone.

Secondary emergency contact email.

Vulnerable needs of Applicant. Please check all that apply. *

Vision - full vision loss

Vision - partial vision loss

Deaf, deafened, or hard of hearing

Mobility

Bedridden

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

Cognitive (e.g. Alzheimer)

Mental Health

Other:

Required

Life sustaining equipment.

Ventilator

Oxygen

Dialysis

Other:

There is a service animal in my home. *

Yes

Other:

I will be able to exit my home by stairs. *

Yes

Not applicable

Other:

I require electricity for life sustaining equipment. *

Yes

Not applicable

Other:

I require electricity after a minimum of _____ hours to stay safe. *

Time

I receive 24 hour support at home. *

Yes

I live alone. *

Yes

Other:

I currenlty receive meals from Meals on Wheels. *

Yes

Other:

I do not have family support locally. *

Yes

Other:

I have trouble with speech or language (e.g. uses an ASL interpreter). *

Yes

Other:

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

Less than 6 hours

6 to 12 hours

12 to 24 hours

24 to 48 hours (1-2 days)

48 to 72 hours (2-3 days)

Greater than 72 hours (3 days or more)

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

Select your contact for your annual updates. *

Applicant

Primary emergency contact

Secondary emergency contact

Other:

Choose one of the following contact methods for the annual updates. *

Phone

Mail

Online

Other:

I allow the Perth Fire Services to utilize information from my VPR registration form for use during emergencies. I understand that I still need to call 911 in an emergency and 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 is an added safeguard where local emergecny service groups will make every effort to increase the possibility of my safety during emergencies. Personal information contained on this form is collected under the authority of the Municipal Freedom of information and Protection of Privacy Act and will be used for the purpose of fire and emergency services. Questions about this collection should be forwarded to the respective local Fire Service. *

I agree to the privacy policy and give consent to the release of personal information only for the purposed indictated above

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