Date of Enrollment Scent Kit:

Date of Enrollment __________ Scent Kit: _________________

1

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.


2

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


3


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: ______________________________________________________


4


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. ***


5

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


6

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: ______________________________________________________________

Documents

Date of Enrollment Scent Kit: