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If you are interested in participating in this program, please complete the information below:
A registry to assist at risk persons
If non-verbal, please indicate the preferred method of communication, i.e. sign language, photos, word approximation
Is the person able to walk?
Describe medical alert ID or other identifying information carried or worn:
I voluntarily give my permission to the Town of Bristol to retain and distribute this information to first responders for the sole purpose of identification and assistance to the person at risk. This information will be kept in the strictest form of confidentiality within the Bristol Police Department. I hereby waive any HIPAA claims that may exist upon the release of information contained on this document.
I am voluntarily withdrawing from the Bristol Police Department’s Emergency Medical Information Program, and request all information obtained by the Bristol Police Department that pertains to me, for the sole purpose of this program, be deleted. I release and discharge the Town of Bristol, its successors, subsidiaries, employees, officers, directors and agents for all claims and liabilities, demands and causes of action known or unknown. Fixed or contingent, which I have claim to have against the Town of Bristol as a result of this withdrawal and do hereby agree not to file a lawsuit to assert such claims.
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