Voluntary Vulnerable Persons Registry

The Voluntary Vulnerable Persons Registry (VVPR) is a voluntary, self-referral list only for residents of Sagamok Anishnawbek who may require support during emergency situations. Sagamok will uphold privacy and confidentiality in the administration of the VVPR.

The VVPR provides important information to Community Wellness and Emergency Management staff, volunteers, and first responders to help them respond appropriately to residents' needs in situations such as sustained power outages, severe storms, and more.

For more information, please contact the Community Wellness Department: 705-865-2171

What can I expect once I’m registered?
Once added, individuals who are included in the Voluntary Vulnerable Persons Registry (VVPR) will receive helpful information or direct contact from Community Wellness and/or Emergency Services staff during emergency events where VVPR is activated.

Name Name First Last
Phone Phone - ### - ### ####
Email
Address Address
Street Address Address Line 2 City
Or

Or Without a stable shelter
Date of Birth Date of Birth / MM / DD YYYY
How many individuals live in the home?
Please describe other household members (For example: #people in Household, ages, additional supports required ):
Would you like to provide a list of medications?
What is your preferred pharmacy?
Do you provide consent for the release of information from your pharmacy?

Do you provide consent for the release of information from your pharmacy? Yes, I provide consent No, I do not provide consent
Do you have a primary care provider?

Do you have a primary care provider? Yes No
Name of provider
Do you provide consent for the release of information from your primary care provider?

Do you provide consent for the release of information from your primary care provider? Yes, I provide consent No, I do not provide consent
Mobility – check all that apply

Mobility – check all that apply Amputation Wheelchair Walker cane Sight cane Other (please describe): Other (please describe):
Respiratory conditions – check all that apply

Respiratory conditions – check all that apply Asthma COPD oxygen therapy Other (please describe): Other (please describe):
Do you use medication for this Respiratory condition?
Do you use medication for this Respiratory condition?
Do you use medication for this Respiratory condition?
Vision impairment

Vision impairment Moderate to severe blindness Other (please describe): Other (please describe):
Hearing impairment

Hearing impairment hearing aid deafness Other (please describe): Other (please describe):
Developmental or neurological conditions– check all that apply

Developmental or neurological conditions– check all that apply Dementia History of psychosis Autism spectrum Other (please describe): Other (please describe):
Please describe and include level of assistance needed to support:
Mental health conditions – check all that apply

Mental health conditions – check all that apply Severe anxiety/depression Do you receive withdrawal management medication? Psychiatric condition
Do you use medication?
In the event of an emergency, would you like a wellness check-in?
Psychiatric condition – please describe:
Do you use medication?
In the event of an emergency, would you like a wellness check-in?
What clinic do you attend? (MINO, Espanola, Ect...)
Consent to release medication information?

Consent to release medication information? Yes, I provide consent No, I do not provide consent
Do you receive mental health counselling?

Do you receive mental health counselling? Yes No
Do you wish to disclose where you receive counselling services?

Do you wish to disclose where you receive counselling services? On Reserve Off Reserve
Do you require electricity for life-sustaining equipment such as oxygen, dialysis, etc.?
Are you without shelter or living in a compromised shelter?
Transportation
Do you receive support from Med Trans OR private transportation?
If yes, what is your usage frequency? What are your medical locations accessed?
Does any of your medical care require you to travel beyond the local area? Please describe:
In the event that the access road is compromised, will you require evacuation?
Are you pregnant?

Are you pregnant? Yes No
How many weeks?
Do you have any complications or a history of complications? Please describe:
Are you receiving cancer treatment or other medical care outside of the community?

Are you receiving cancer treatment or other medical care outside of the community? Yes No
Please describe:
Consent
I understand that the Sagamok Anishnawbek Emergency Services will provide the information I included in my Voluntary Vulnerable Persons Registry (VVPR) registration to local first responders for use during emergencies. I understand that if I rely on electricity for life-sustaining equipment such as oxygen, my information may also be provided to Emergency Management volunteers and service providers. I know that it is important for me to ensure that the VVPR 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 to be prepared to remain safe for at least three days. I recognize that the VVPR 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. I understand that my information may be available to authorized local first responders and volunteers during the event of an emergency.
Do you understand the information shared with you today?

Do you understand the information shared with you today? Yes No
Do you give consent?

Do you give consent? Yes No
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Voluntary Vulnerable Persons Registry

Voluntary Vulnerable Persons Registry

Transportation

Consent