Date of Enrollment __________ Scent Kit: _________________
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United Way’s ReUnite program is currently offered in Lee, Hendry and Glades Counties.
Individuals whose primary residency is outside of the three-county area may be eligible
to receive a scent kit but, will not be entered into the Lee, Hendry, or Glades County
emergency databases. Individuals outside of the above mentioned counties should
contact their local law enforcement for search and rescue resources available to them.
The ReUnite Program is a community based collaborative program between the Lee County Sheriff’s Office and the United Way, a non-profit organization, dedicated to improving the quality of life in our community. The goal of this program is to aid first responders in search and rescue operations for at risk individuals with cognitive and/or behavioral disorders who may be prone to wandering or getting lost. The information outlined in this application provides critical information to first responders in the event an at-risk individual (“Participant”) becomes lost. Providing this information in advance enables first responders to move forward in their search efforts with critical information provided to them in advance.
Use of Information and Public Records Notice
The undersigned legal caregiver/ legal guardian, individually and on behalf of the named Participant
hereby authorizes the Lee County Sheriff’s Office and the United Way to use all information provided in
this application in any way the Lee County Sheriff’s Office and the United Way deem necessary as part of
the ReUnite Program.
Date of Enrollment __________ Scent Kit: _________________
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Please Print Answers
THIS APPLICATION ITSELF AND ALL INFORMATION PROVIDED AS PART OF THIS APPLICATION, IS
SUBJECT TO FLORIDA’S BROAD PUBLIC RECORDS LAW AND SUBJECT TO DISCLOSURE PURSUANT TO
CHAPTER 119, FLORIDA STATUTES.
Signed: ______________________________________________________________________________
(Legal Caregiver/Legal guardian’s Signature confirming acceptance and understanding)
(Date)
Printed Name of the legal caregiver/legal guardian filling out this application: ______________________
____________________________________________________________________________________
Participant Information as of _____________________________________ (enter today’s date)
Please circle : Scent Kit
Participant Personal Data Last Name: ____________________ First: _______________________ Middle: ____________
Nickname: ____________________________________________________________________________
Sex: ______________________ Race: ______________________________
Birth Date: _____________________________ Age: _________________________________________
Current Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Home Phone: __________________________________ Cell Phone: _________________________
Does the Participant speak/understand English? Yes ________ No _________
If no what is the Participant’s first language? ________________________________________________
County of Residence: Lee Hendry Glades
Date of Enrollment __________ Scent Kit: _________________
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First Emergency Contact Information Name: _______________________________________________________________________________
Relationship to Participant: _____________________________________________________________
Current Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Home Phone: __________________________________ Cell Phone: _____________________________
Email: _______________________________________________________________________________
Second Emergency Contact Information Name: _______________________________________________________________________________
Relationship to Participant: ______________________________________________________________
Current Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Home Phone: __________________________________ Cell Phone: _____________________________
Email: _______________________________________________________________________________
Physical Description of Participant Height: ___Ft. ____Inches. Weight: ___________Lbs.
Eye Color: ______________ Hair Color: ____________
*Please include a recent picture of participant. Email to [email protected]
Any other distinguishing features, marks, scars, tattoos, etc.: ___________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Any known physical disabilities: ______________________________________________________
Date of Enrollment __________ Scent Kit: _________________
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Relevant Psychological, Cognitive, or Behavioral Health Conditions or Diagnosis (i.e. Autism Spectrum
Disorder, Alzheimer’s, etc.): ______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Personality and Social Habits Does participant have a fear of dogs? Yes ____ No____
Any known calming techniques/suggested ways to communicate and interact if applicable: ___________
_____________________________________________________________________________________
_____________________________________________________________________________________
Wandering Experiences Has the Participant ever been lost before? Yes ____ No ____
If yes, explain: _________________________________________________________________________
Was Participant returned after his/her own efforts or was he/she located by searchers? ______
Location the Participant was found? _______________________________________________
I certify that that I am the legal caregiver/ guardian of this Participant and I am authorized to provide the
above information as part of this application.
Under penalties of perjury, I declare that I have read the foregoing [document] and that the facts stated in it are true.
_____________________________________________________________________________________
(Signature of Legal Caregiver/Legal Guardian of Participant) (Date)
***Please provide a picture of the Participant as part of this application along with
verification of your role as the legal caregiver/ legal guardian authorized to provide
the information found in this application. ***
Date of Enrollment __________ Scent Kit: _________________
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UNCONDITIONAL AND
FULL RELEASE AND
HOLD HARMLESS
I, ________________________________________________________________, on behalf of
myself as the legal caregiver/ legal guardian and on behalf of the participating Participant
understand that by completing this application, signing this waiver, providing the Participant’s
information to the United Way and Lee County Sheriff’s Office, using a tracking device, or
otherwise using a DNA kit will in no way guarantee the safety of the Participant nor guarantee
the safe return or any other specific results in the event that the Participant identified in this
application gets lost or wanders.
I fully understand that this program is just an additional tool for first responders to use in the
event the Participant becomes lost or wanders. I also understand that there are numerous
foreseeable and unforeseeable risks and dangers that this program cannot protect against and
in consideration for the opportunity to participate in the ReUnite Program:
I ON BEHALF OF MYSELF AND THE PARTICIPANT THEREFORE AGREE TO INDEMNIFY AND
FOREVER HOLD HARMLESS AND DISCHARGE TO THE FULLEST EXTENT THE LAW ALLOWS, THE
UNITED WAY, INC., LEE COUNTY AND THE LEE COUNTY BOARD OF COUNTY COMMISSIONERS,
CARMINE MARCENO, AS SHERIFF OF LEE COUNTY, A CONSTITUTIONAL OFFICER FOR THE STATE
OF FLORIDA, INDIVIDUALLY AND IN HIS OFFICIAL CAPACITY, AND ALL MEMBERS OF THE LEE
COUNTY SHERIFF'S OFFICE, INDIVIDUALLY AND IN THEIR OFFICIAL CAPACITY, AND ALL OF
THEIR EMPLOYEES, APPOINTEES, AGENTS, CONTRACTORS AND SUB-CONTRACTORS, FOR ANY
AND ALL CLAIMS, CAUSES OF ACTION, DEMANDS OR DAMAGES, AND COSTS (TO INCLUDE
REASONABLE ATTORNEY'S FEES) PRESENT, PAST AND FUTURE, ARISING IN LAW OR EQUITY,
CONTINGENT OR OTHERWISE, INCLUDING BUT NOT LIMITED TO ANY AND ALL CLAIMS WHICH
ALLEGE NEGLIGENT ACTS AND/OR OMISSIONS COMMITTED BY THE UNITED WAY, INC., LEE
Date of Enrollment __________ Scent Kit: _________________
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COUNTY AND THE LEE COUNTY BOARD OF COUNTY COMMISSIONERS, MEMBERS OF THE LEE
COUNTY SHERIFF’S OFFICE, OR SHERIFF CARMINE MARCENO REGARDLESS OF WHETHER THE
CLAIMS ARISE OUT OF ANY DAMAGE, LOSS, PERSONAL INJURY, OR DEATH TO MYSELF OR THE
PARTICIPANT OR ARE IN ANY WAY RELATED TO THE REUNITE PROGRAM, THE USE OF ANY
TRACKING DEVICE, OR ANY DNA KIT.
I also understand that neither Sheriff Marceno, the Lee County Sheriff’s Office, nor the United
Way are in any way responsible for the accuracy and use of any DNA kit or tracking device and
neither Sheriff Marceno, Lee County Sheriff’s Office nor the United Way make any
representations, warranties, or guarantees whatsoever regarding the use or accuracy of any
tracking device, DNA kit, or the ReUnite program itself.
I alone am responsible and assume all and any risk and liability for how I use and maintain the
DNA Kit and any tracking device.
Notwithstanding anything to the contrary, nothing in this Waiver, this application, or any other
document related to this Waiver or the ReUnite Program is intended nor shall it be construed or
interpreted to waive or modify any immunities and limitations on liability or damages entitled to
any government entity, Sheriff Marceno, and the Lee County Sheriff’s Office provided for in
Florida Statutes section 768.28 as now worded or as may hereafter be amended and the strict
financial limitations set forth therein. The limitations on liability and damages as found in the
768.28 shall be applicable to any all claims or defenses including but not limited to those arising
under contract or tort, including but not limited to claims of negligence. The validity,
interpretation and enforcement of this Release and all claims or disputes arising from and/or
related to this Release as well as any and all claims between the any party who may be subject
to this Release will be governed by and construed in accordance with the laws of the United
States and Florida. Any and all litigation related to this waiver in any way, including, but not
limited to, enforcement of the terms, rights, duties, and obligations imposed herein, shall lie
exclusively in the state or federal courts situated in Lee County, Florida.
You must be at least 18 years old to sign this waiver and must be the legal guardian or legal
caregiver for the Participant
SIGNATURE OF LEGAL CAREGIVER/LEGAL GUARDIAN OF PARTICIPANT:
______________________________________________________________________________
PRINT: ________________________________________________________________________
EFFECTIVE DATE: ______________________________________________________________
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