Personal Information of Applicant
Please provide the following information about the individual choosing to provide their information for the Rideau Lakes Vulnerable Persons Registry.
I receive Home Care Services
Primary Emergency Contact Information
Please provide the following information about the primary emergency contact for the individual identified above.
Secondary Emergency Contact Information
Please provide the following information about the secondary emergency contact for the individual identified above.
Vulnerable Needs of Applicant
Please check all that apply
Life sustaining equipment
There is a service animal in my home
I will be able to exit my home by stairs
I require electricity for life sustaining equipment
I receive 24 hour support at home
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. uses an ASL interpreter)
How long can you care for yourself in a large-scale emergency?
Please provide any important additional information that will help first responders assist you during an emergency (for example, use a wheelchair).
Select your preferred preferences for your annual updates
Choose one of the following update methods
Please read and sign below for your application to be reviewed:
I allow the Township of Rideau Lakes to provide the information I included in my VPR registration form to Emergency Responders 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 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 emergency 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 Township of Rideau Lakes Fire Department.
I consent to the release of my personal information for the purposes indicated above.