Welcome To Valley County Idaho

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Vulnerable Population Registry

Home

Groups

911 Communications Center

Patient Information

*Patient's Name

(Last. First, Middle)

Nickname

*Date of Birth

(mm/dd/yyyy)

Patient's Physical Address

*Street Address

Address Line 2

*Postal/ Zip Code

*City

*State

Patient's Primary Phone

xxx-xxx-xxxx

Primary Contact Email

(An acknowledgement of this information will be sent to this email address)

Patient's Cell Phone

xxx-xxx-xxxx

*Relationship

Medical Information

Secondary Contact Information

*Patient's Diagnosis

Secondary Contact Name

(Last, First)

Additional Diagnosis

Secondary Contact Phone Number

xxx-xxx-xxxx

Additional Medical Information

Secondary Alternate Phone Number

xxx-xxx-xxxx

Medicinal Requirements

(Insulin with Needles, Requires daily meds, Oxygen)

Secondary Contact Address

Physical Description

Street Address

Height

Address Line 2

Weight

(In Pounds)

City

Gender

Postal / Zip Code

Scars/ Marks/ Tattoos

Relationship

Race

Valid Drivers License

Hair Color

Glasses

Driver License or Identification Information

State

Driver's License/ Identification Card Number

Special Information

Living Status

Care Facility

Primary Language

Communication Method

(Verbal, Non-Verbal, Hearing Difficulties, Picture/Assisted Communication Devices, Sign Language)

Wandering Tendencies

(Places they like to go, Things they are drawn to, Where they have gone in the past)

Safe Topics for Registered Person

Does the registered person fear police?

Does the registered person fear paramedics?

Does the registered person fear firefighters?

Does the registered person have access to weapons?

Weapons Description

Weapons Type

(Toy Gun, BB Gun, etc.)

Are there any known techniques that successfully deescalate the person?

Does the registered person have any triggers?

Is there anything that helps to calm the registered person?

Methods of Transportation

Patient's Form of Transportation

(Walking, Bicycle, ATV, Snowmobile, Automobile, etc.)

Vehicle Information

Vehicle Registered Owner

Make

Model

Year

Color

Plate

Plate State

School Information

School

Grade Level

Employer Information

Employer

Street Address

Address Line 2

City

State

Postal/ Zip Code

Employer Contact

Work Hours

Primary Contact Information

*Primary Contact Name

(Last, First)

*Primary Phone Number

xxx-xxx-xxxx

Alternate Phone Number

xxx-xxx-xxxx

Primary Contact Address

*Street Address

Address Line 2

State

Trusted Individual

Is there someone other than the contact person(s) who the registered person trusts?

Please provide the Trusted Individual's name.

(Last, First)

Please provide the Trusted Individual's phone number.

xxx-xxx-xxxx

Attachments

Attachments are for identifiers E.G. Picture of individual, Vehicle, Tattoos, etc.

Confirm

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General Information

Staff Directory

Dispatch@co.valley.id.us

Phone Numbers

(208) 382-5160

Emergencies: Dial 911

Non-Emergency

Crisis Line

Jail

Records

Civil Process

Drivers License

Sheriff Kevin Copperi

Contact Info

Valley County, Idaho
219 N. Main Street
PO Box 1350
Cascade, ID 83611

Resources

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