Form Center

(a) Every person who willfully obtains personal identifying information, as defined in subdivision (b) of Section 530.55, of another person, and uses that information for any unlawful purpose, including to obtain, or attempt to obtain, credit, goods, services, real property, or medical information without the consent of that person, is guilty of a public offense, and upon conviction therefor, shall be punished by a fine, by imprisonment in a county jail not to exceed one year, or by both a fine and imprisonment, or by imprisonment pursuant to subdivision (h) of Section 1170.

I acknowledge that by submitting this form the information being provided is truthful, current and valid and that I am authorized to submit it on behalf as the legal guardian, care giver, or conservator with authority to submit it on behalf of another. I further understand that by enrolling myself or someone else into the Riverside Sheriff's Department Special Needs Reunification Program the personal information entered may be used by emergency personnel, including but not limited to, law enforcement officers, emergency medical services (first aid/paramedics), and fire department personnel in the event of a personal emergency or other emergency situation. It is further understood that completion of this form and participation in the Riverside Sheriff's Department Special Needs Reunification Program is voluntary and cannot guarantee and is not intended to convey or warrant, either express or implied, as to the outcomes, promises, or benefits from the use of this form and participation in this program. I understand that any and all health-related information on this form is voluntary and that I am willingly providing said information in light of any and all related and applicable privacy laws. I understand I must update this information on a yearly basis to have my loved one’s registry stay current and active. I acknowledge that the information submitted must be updated on an annual basis. If the registrants address should change, I will immediately update the account with current and correct address. By submitting this form, I acknowledge that I understand these disclaimers.