Fountain County, IN Citizens at Risk Database
**Registration Information Will Be Kept Confidential**
*One survey completed per person*
This survey compiles information used to assist citizens and first responders to prioritize response for the at risk population. 
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Address (Physical address, NO PO Boxes) *
City *
Zip Code *
Township *
Phone Number *
Date of Birth *
MM
/
DD
/
YYYY
Eye Color
Hair Color
Height
Weight
Primary Language *
Characteristics (Check all that apply)
Other characteristics (Please include name and location. e.g. tattoo on left leg)
Physician Name
Physician Phone Number
Are you Oxygen Dependent?
Clear selection
Are you able to get in and out of your home without assistance?
Clear selection
Do you utilize a walker to get around?
Clear selection
Do you utilize a wheelchair to get around?
Clear selection
Is there a dog in your home?
Clear selection
Do you Drive?
Clear selection
Would you need emergency assistance in the event of an extended power outage?
Clear selection
Your Vehicle Make?
Your Vehicle Model?
Your Vehicle Year?
Yor Vehicle Color?
Do you carry identification?
Clear selection
Emergency Contact #1 Name
Emergency Contact #1 Address
Emergency Contact #1 Phone Number
Emergency Contact #1 Relationship to you
Emergency Contact #2 Name
Emergency Contact #2 Address
Emergency Contact #2 Phone Number
Emergency Contact #2 Relationship to you

I, (Signed below), authorize the use of this information with the EMS, Fire, and Police Departments operating in Fountain County and with other agencies where I receive services. I understand that this information will be filed and kept confidential to the extent of the law and used only for purposes of identification and assistance related to the safe return efforts and related first responder assistance activities. Authorization can be withdrawn at any time.


If you have read and agreed with these terms please type your name below.


Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Fountain County.

Does this form look suspicious? Report

Google Forms