"*" indicates required fields Name of Parent or Guardian completing this form:* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Cell Phone*Work PhoneAlternate Parent or Guardian: Full Name Phone #:Name of Child or Special Needs Adult:* First Last Age*Date of birth* MM slash DD slash YYYY NicknameHeight*Weight*Hair Color*Eye Color*Gender*Daycare / School / Care Facility:*Phone #:*Child / Adult Medical Classification*"Other"- Please specify the individual's medical classification. Please list any special considerations or needs.*List places that child likes to visit (friend's houses, specific stores or attractions).*The following release for the access, storage and dissemination of protected records is required for the form to be valid. By entering your name below, you agree to the terms of the Vulnerable Adult & Special Needs Child Registry.*I authorize the disclosure of the above specified health records to the individuals affiliated with the Harrisville Police Department (HPD) and North View Fire District (NVFD). I understand that, if the persons or organizations I authorize to receive and/or use medical records are not subject to the federal or state health information privacy laws, they may further disclose the medical records in direct performance of their duties associated within the intent of HPD’s Vulnerable Adult & Special Needs Child Registry, in which case, it may no longer be protected by the health information privacy laws.This authorization is valid for one calendar year. It will expire one year from __________. I understand that I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent by email to police@harrisvillecity.gov. I recognize that these records, once received by the department, may not be protected by the HIPAA Privacy Rule, but will become private records protected by HPD policy and 5 U.S.C. § 552a(b).* MM slash DD slash YYYY Please fill in the blank with the appropriate date This form is not to be reproduced or disseminated without the express permission of the Harrisville Police Department. Δ
