Form Center

2. 
6. Person Registering Vulnerable Person - Your Information
8. This program is only available to residents of Randolph County.
10. Your Name*
11. Email Address*
13. Your Phone Number*
14. Relationship to Vulnerable Person*
16. Address
18. City
19. State
20. Zip Code
24. Vulnerable Person Information - Please provide as much detail as possible about the vulnerable person.
26. Vulnerable Person Name*
27. Nickname
29. Email Address
31. Vulnerable Person's Address
33. City
34. State
35. Zip Code
37. Phone Number
39. Living Arrangements*
    -- Select One --AloneWith SpouseWith FamilyWith Caregiver(s)Care FacilityWith Roommate(s)
41. Other occupants' information (name, phone, etc.)
45. Identifying Information
47. Date of Birth*
48. Race*
    -- Select One --Asian or Pacific IslanderBlackIndian or Alaskan NativeWhite/Hispanic LatinUnknownWhite/Non-Hispanic
49. Gender*
    -- Select One --FemaleMaleTransgender
50. Height (feet and inches)*
52. Weight*
53. Eye Color
    -- Select One --BlueBrownGreenHazelOther
54. Hair Color*
    -- Select One --BlondeBrownBlackBaldRedGrayOther
56. Hairstyle/Length*
    -- Select One --BraidedBushyCurlyDreadlocksLongMediumShouler LengthShortStraight
57. Facial Hair*
    -- Select One --NoneFull BeardGoateeMustacheOther
58. Build*
    -- Select One --HeavyMediumSlenderSmallStocky
62. Medical Information
64. Glasses*
    -- Select One --YesNo
65. Glasses Type
    -- Select One --BifocalsGlasses - GenericContact LensesMonaclePlastic FrameWire FrameTri-focal / Progressive
66. Teeth/Dental Condition*
    -- Select One --BracesCrookedDiscoloredDenturesMissing TeethNo teethPartialProtrudingStraightNA
67. Hearing Aids*
    -- Select One --YesNo
69. Any visible identifying marks (amputations, deformities, scars, tattoos, etc.)*
71. Diagnosis

    1. Alzheimer's
    2. Aspergers
    3. Attention Deficit/Hyperactivity Disorder
    4. Autism
    5. Blind/Low Vision/Vision Impairment
    6. Cerebral Palsy
    7. Deaf/Hearing Loss/Low hearing
    8. Dementia
    9. Down Syndrome

    1. Epilepsy/Seizures
    2. Huntington Disease
    3. Intellectual Disability
    4. Mental Illness
    5. Other Brain Illness
    6. Other Developmental Disability
    7. Other Mental Disability
    8. Physical Disability
    9. PTSD
72. Level of functionality*
    -- Select One --Low support requiredModerate cognitive declineModerate support requiredNo cognitive declineSevere cognitive declineSevere support required
74. Medical Provider Name and Contact
76. Medicinal Requirements

    Ex. Insulin with Needles, Requires daily meds, Oxygen

80. Location Information
82. History of Prior Wandering

    1. Yes
    2. No
83. Cell Phone or Tracking Device

    1. Cell
    2. GPS Tracking
    3. NA
84. Are you interested in a Guardian Project tracking device for the vulnerable person? 

    The device and GPS tracking service is funded through a federal grant and free of charge for the vulnerable person.

    1. Yes
    2. No
86. Employer/School
87. Social Media Accounts

    Vanity Names/User Names

89. Known Friend/Associate
90. Phone Number
92. Email Address
94. Method of Travel
96. Wandering Tendencies

    Places they like to go, things they are drawn to, where they have gone in the past

100. Communication Information
102. Is the person verbal?*

     1. Yes
     2. No
103. Will the person respond to their name?

     1. Yes
     2. No
104. Preferred communication/language(s)*
106. Prior LEO, Military or Specialized Training?

     1. Yes
     2. No
107. If yes, please explain in detail
111. Behavior and Trigger Information
113. Does the registered person fear police?

     1. Yes
     2. No
114. Does the registered person fear paramedics?

     1. Yes
     2. No
115. Does the registered person fear firefighters?

     1. Yes
     2. No
116. Does Vulnerable Person have access to weapons?*

     1. Yes
     2. No
118. Does the person respond negatively to bright lights, loud noises or sirens?*

     1. Yes
     2. No
119. Does the person avoid or dislike eye contact?

     1. Yes
     2. No
120. Does the person respond negatively to touch?

     1. Yes
     2. No
121. Does the person respond negatively to animals?

     1. Yes
     2. No
123. What behavior/s does person exhibit?

     1. Kicking
     2. Hittting
     3. Biting
     4. Stimming

     1. Self-Harming
     2. Self-Talking
     3. Other
124. Alcohol/Drug Use

     1. Yes
     2. No
126. Calming or soothing tactics

     Catch phrases or words the person likes to use or repeat, topics the person enjoys talking about, music, or favorite toys.

128. Is there any other information you would like to provide?
130. Interested in the GPS watch?

     1. Yes
     2. No
134. Secondary/Emergency Contact
135. Secondary/Emergency Contact Phone Number
137. Upload a photo - please submit a clear photo*
141. IMPORTANT - PLEASE READ BEFORE SUBMITTING FORM
143. Please review the following before completing and submitting this form.
145. Participation in this registry is VOLUNTARY.
     • The information on this form will be added to Randolph County Sheriff's record management system and may be distributed to first responders in order to better care for you or your family members.
     • We respect the right to privacy and will make every attempt to ensure that all personal information remains confidential, unless release of the information is required by law.
147. INFORMATION IS ACCURATE AND TRUTHFUL

     I acknowledge that the information provided is accurate and truthful and submitted voluntarily for the purpose of assisting first responders in more effectively responding to a potential emergency involving the vulnerable person.

149. INFORMATION IS ACCURATE AND TRUTHFUL*

     I acknowledge that the information provided is accurate and truthful and submitted voluntarily for the purpose of assisting first responders in more effectively responding to a potential emergency involving the vulnerable person.

     1. Agree
151. USE AND SHARING OF INFORMATION*

     I consent to the use and sharing of this information for the above listed purposes.

     1. Agree
153. KEEPING INFORMATION UPDATED*

     I further acknowledge that it is my responsibility to update the information provided if there are changes.

     1. Agree
155. GPS CELLULAR WATCH REQUIREMENTS:*

     As a participant, I/we understand: 

     1. Participating in this program is voluntary.  Individuals and their caregiving family members may leave the program at any time.
     2. Technology provided to the individual participating in the GUARDIAN PROJECT Program is property of Randolph County Sheriff's Office and must be returned in the event that participation is terminated.
     3. A representative from the Sheriff's Office will make monthly contact with the primary caregiver in order to collect updates on the use of the location tracking of the GPS device and any issues experienced not already reported.  
     4. Caregivers are responsible for keeping the location tracking technology appropriately charged and maintained throughout the individuals' participation in the program.   Caregivers understand that they will be responsible for daily charging of the device and assisting the individual in daily wearing of the device, including lockable wristbands if elected for use.
     5. Participation in the program will be discontinued if participant does not utilize the device or no longer requires location monitoring due to a change in situation. Failure to consistently use device or participate in the program is grounds for termination from the program.
     6. Loss of or intentional damage to equipment issued may constitute immediate termination from the program. Participants may choose to pay for lost/damaged equipment within 30 days of loss or damage to remain in compliance. Failure to meet the 30-day deadline will constitute immediate termination from the program and will require a surrender of all equipment, including door alarms if issued.
     7. Caregiver must have a smartphone. Cell phone software must remain updated to support the proper functioning of the application

     The Randolph County Sheriff's Office will:

     1. Provide the participating individual with a wearable GPS tracking device, an optional lockable wristband, and an optional door alarm.
     2. Provide monthly service for the device for the term length of the program.  The term length may be extended; however, any continuation of the program is strictly contingent on continued funding.  Current grant funding is in effect until September 30, 2027.
     3. Provide education and training to family members and caregivers on the use of the device and the accompanying cell phone application, lockable wristband, and door alarm technology.  The Sheriff’s Office is available throughout participation in the program for assistance with using the device(s)/application and helping caregivers troubleshoot any potential technical issues.
     4. Have (at minimum) monthly communication with the caregiver to follow up on progress, use of the device, and any technical difficulties.
     5. Access location data only in the event of an emergency/wandering incident and will not routinely monitor participant location.

      

     Continued availability of this program is contingent upon the Randolph County Sheriff's Office receiving grant funding to sustain the program.  This agreement is in effect until participant withdrawal from the program or termination from the program, or no later than September 30, 2027.

      

     1. Agree
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157. 1. Receive an email copy of this form.
158. Email address

     This field is not part of the form submission.

159. Submit

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