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2. Person to be registered
4. Last Name
5. First Name
6. Middle Initial
8. Sex

   1. Male
   2. Female
9. Race
11. Home Address
12. Apt #
13. What floor do you live on?
15. City
16. State
17. Zip Code
19. Do you live in a mobile home?

    1. Yes
    2. No
20. Name of Trailer Park/Complex
22. Are you a seasonal resident?

    1. Yes
    2. No
23. What months are you here?
25. Home Phone
26. Work Phone
27. Cell Phone
29. Email Address
31. Ethnicity
32. Height
33. Weight
35. Complexion
36. Build
37. Hand (L/R)
39. Hair
40. Hair Style
41. Eyes
43. Occupation
44. Employer
46. Employer Address to include City, State, and Zip
50. Select applicable medical disabilities

    1. Legally Blind
    2. Deaf
    3. Sign Language/ASL

    1. Terminal
    2. Contagious Disease
52. Specify other chronic medical disabilities

    1. ADHD
    2. Autism/Asperger's Syndrome
    3. Alzheimer's Disease
    4. Brain Injury
    5. Down Syndrome

    1. Cerebral Palsy
    2. Diabetic
    3. Epilepsy
    4. Multiple Sclerosis
54. Check applicable special equipment that registered person in dependent on

    1. Wheelchair
    2. Walker/Cane
    3. Crutches
    4. Life Support System

    1. Dialysis
    2. Insulin Dependent
    3. IV
    4. Oxygen
56. If oxygen is needed, how many hours per day?
57. Do you have a portable tank?

    1. Yes
    2. No
59. If the registered person has a tendency to wander, please describe places he/she have been found recently or may choose to go.
61. Medical or psychological concerns relevant to sheriff attempting to assist the registered person to remain safe and stay or leave home.
63. Items the registered person wears/possesses on a regular basis (such as medical devices, personal items or objects).
65. Suggestions for ways the sheriffs’ deputy can approach and help the registered person.
67. Regular behaviors and/or special interests
69. Medications the registered person MUST take to avoid a medical emergency
73. I wish to have the ARE YOU OKAY System contact me

    1. Daily (or pick days)
    2. Monday
    3. Tuesday

    1. Wednesday
    2. Thursday
    3. Friday

    1. Saturday
    2. Sunday
75. Time system should contact me

    Please enter the time and am/pm

77. In the event that I do not answer the Are You Okay? call at the date(s) and time I indicated above, I authorize the Sheriff's Office to send a law enforcement officer to check on my well-being. I further authorize the listed people to be contacted, to check on my welfare or offer further assistance or aid
79. Primary Contact
81. How related?
83. Last Name
84. First Name
85. Middle Initial
87. Sex
88. Race
90. Primary Caretaker Home Address

    Please enter full address to include City, State, Zip Code, and Apt# if applicable.

91. Email Address
93. Home Phone
94. Work Phone
95. Cell Phone
97. Ethnicity
98. Height
99. Weight
101. Complexion
102. Build
103. Hand (L/R)
105. Hair
106. Hair Style
107. Eyes
109. Occupation
110. Employer
112. Employer Address

     Please enter complete address to include City, State, and Zip Code.

114. Secondary Contact
116. How related?
118. Last Name
119. First Name
120. Middle Initial
122. Sex
123. Race
125. Secondary Caretaker Address

     Please enter full address to include City, State, Zip Code and Apt # if applicable.

126. Secondary Caretakers Email
128. Home Phone
129. Work Phone
130. Cell Phone
132. Ethnicity
133. Height
134. Weight
136. Complexion
137. Build
138. Hand (L/R)
140. Hair
141. Hair Style
142. Eyes
144. Occupation
145. Employer
147. Employer Address

     Please enter complete address to include City, State and Zip Code.

151. Name (Self or Legal Guardian)

     Please enter your name

153. Waiver of Liability

     I (the above entered name) (self or legal guardian), hereby voluntarily and knowingly agree to release and hold Harmless the Cochise County Sheriff's Office and/or any other Public Safety Organization who responds to assist against any claim in relation to services received through the Are You Okay program and Vulnerable Populations Database.

     I understand and acknowledge that the Cochise County Sheriff's and other Public Safety organizations are providing this program as a public service for no compensation. I also understand and acknowledge that the Cochise County Sheriff's Office may, in their sole discretion, terminate this service at any time. I further understand and acknowledge that technical problems or human error may result in failure of the service at any time. I understand that my participation in this program is purely voluntary.

     In consideration of these factors, I hereby waive, release, and hold harmless the Cochise County Sheriff's Office from any claim arising from a failure for any reason to provide the services contemplated by this agreement. I further agree to waive, release, and hold harmless the Cochise County Sheriff's Office against any claim for direct, incidental, or consequential damages arising from any act or omission of the Cochise County Sheriff's Office, their volunteers, or employees, incurred in connection with the Cochise County Sheriff's office participation in this program.

155. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
157. Electronic Signature
Leave This Blank:


159. 1. Receive an email copy of this form.
160. Email address

     This field is not part of the form submission.

161. Submit

* indicates a required field