Voluntary Registry for People with Disabilities
The Winneshiek County Sheriff's Office, the Winneshiek County 9-1-1 Communications Center, and the Decorah Police Department are offering a voluntary registry service for people with disabilities who may require special assistance in emergency or crisis situations. This confidential registry may provide essential information that will allow law enforcement and other emergency workers to address the needs of residents of all abilities. This registration will not be effective without the signed Waiver and General Release Form; signed by the Registrant or the authorized representative.
E-Sign for the Waiver & General Release Form
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DATE AND TIME
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Month
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Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
CHECK ONE
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Initial Application.
Update to an Existing Application.
PERSON FILLING OUT THIS FORM
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PERSON FILLING OUT THIS FORM
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I am completing this registration for myself as the Registrant.
I am completing this registration as the authorized representative of the Registrant.
If you are completing this registration as a representative of the Registrant, please provide your legal relationship to the Registrant.
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Parent
Sibling
Guardian
REGISTRANT INFORMATION
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REGISTRANT INFORMATION - ANY IDENTFYING CHARACTERISTICS?
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REGISTRANT INFORMATION - DOES THE REGISTRANT LIVE ALONE?
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Yes
No
IF "NO" ABOVE, PROVIDE THE FOLLOWING INFORMATION ABOUT THE ROOMMATE(S).
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REGISTRANT INFORMATION - DOES THE REGISTRANT LIVE IN A GROUP HOME?
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Yes
No
IF "YES" ABOVE, PROVIDE THE FOLLOWING INFORMATION.
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PRIMARY CARE PROVIDER
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ADDITIONAL EMERGENCY CONTACT
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SPECIAL CIRCUMSTANCES AND SAFETY CONCERNS
ARE THERE ANY FIREARMS IN THE HOME?
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Yes
No
IF "YES" ABOVE, ARE THE FIREARMS SECURED WITHIN THE HOME?
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Yes
No
IF "YES" ABOVE, DESCRIBE THE FIREARMS AND HOW THE FIREARMS ARE SECURED WITHIN THE HOME.
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DOES THE REGISTRANT HAVE ACCESS TO FIREARMS?
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Yes
No
DOES THE REGISTRANT HAVE A HISTORY OF VIOLENCE?
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Yes
No
IF "YES" ABOVE, EXPLAIN THE CIRCUMSTANCES.
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PLEASE INDICATE ANY IMPAIRMENT OR DISABILITY THAT REQUIRES SPECIAL ACCOMMODATIONS IN EMERGENCIES.
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PLEASE SPECIFY ANY COGNITIVE, VERBAL, HEARING, TACTILE, OR VISUAL IMPAIRMENT THAT MAY REQUIRE SPECIAL ACCOMMODATIONS IN COMMUNICATING WITH OTHERS.
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HOBBIES OR INTERESTS - THIS WILL HELP US TO MAKE A PERSONAL CONNECTION TO THE REGISTRANT.
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IS THE REGISTRANT CURRENTLY EMPLOYED OR VOLUNTEERING?
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Yes
No
IF "YES" ABOVE, PROVIDE THE FOLLOWING INFORMATION.
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ANY ADDITIONAL INFORMATION YOU BELIEVE IS IMPORTANT.
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