Borough of Hopatcong, New Jersey
111 River Styx Road, Hopatcong, New Jersey 07843
Phone: 973-398-5000
Thank you for taking the initiative to be a part of the Hopatcong Safely Back Home Program
Safely Back Home™ is an innovative program that provides additional peace of mind to families and caregivers of people who wander. The Safely Back Home™ patent-pending process uses ID information imprinted on personal garments to help the public and the police assist an individual who has become lost.
The Safely Back Home™ Program was developed in response to a need to provide assistance to individuals who are incapable of providing identifying information in situations where they become lost.
When an individual who wanders and appears lost is wearing a Safely Back Home™ imprinted garment, the concerned person who notices them can quickly contact HPD with location details and a rescue ensues.
The Safely Back Home™ program enables police and first responders to understand how to communicate effectively with your family member, allowing your family member to remain calm during their rescue.
Families/Caregivers provide medical and personal information about the family member. All information remains confidential and privacy protected. Wherever your family member is wandering (in NJ/USA) – police departments are able to electronically share this information in coordinating the rescue.
Fill the form online below or download a copy of blank form from here.
Click here to download a blank form.
The enrollment application should be filled out by the family member/caregiver (the Authorized Representative) on behalf of the individual (the Applicant) who will be enrolled in the HPD Safely Back Home program. Providing this detailed information in advance of any need ensures an efficient and speedy response by Emergency Services personnel. Please be as thorough and complete as possible.
Upon receipt and review of the enrollment application, a HPD Safely Back Home ID number specific only to the applicant will be issued. The family member/caregiver will receive this HPD Safely Back Home ID# via email. The family member/caregiver will also receive notification that the application has been accepted.
IMPORTANT: All information submitted on the enrollment form will be kept confidential and stored in a secure database maintained by the HPD.
This application is divided into three sections: • The first section requires information about you, the Authorized Representative. • The second section is for additional emergency contact information. Should you not be available or if we are unable to get in touch with you, only an authorized person(s) listed on the enrollment form will be contacted. • The third and last section of the application is where you will provide information about the individual being enrolled, the Applicant. All sections are to be filled out by you, the Authorized Representative.
THIS NUMBER WILL BE PROVIDED TO AUTHORIZED REPRESENTATIVES FROM SAFELY BACK HOME (SBH) TO BE USED AND PRINTED ON SBH GARMENTS/ATTIRE TO ASSIST THE APPLICANT IN BEING RESCUED AND RETURNED TO THEIR FAMILIES.
MF
If an emergency arises and we are unable to reach the authorized representative, we will contact the individual(s) you designate below. Please provide contact information for two additional people that the HPD may contact..
MaleFemale
Is the Applicant Verbal or Non-Verbal ? VerbalNon-Verbal
Does the Applicant live alone? YesNo
Does the Applicant understand English? YesNo
If NO, what language is understood?
Spoken word onlyWritten and spokenSign Language
Other relevant Medical Conditions (please check all that apply): Blind Deaf No Sense of Danger Prone to Seizures Cognitive Impairment None of the above
Any other medical condition(s) not shown above:
Applicant’s specific diagnosis?
Does the applicant wear glasses?
YesNo Contacts?YesNo Sunglasses?YesNo
If the applicant wears corrective eye wear, what degree of vision does he/she have without the eye wear? NonePoorFair
Does the Applicant wear a hearing aid? YesNo If yes, Left EarRight Ear
What type of hearing does he/she have without the hearing aid? NonePoorFair
Does APPLICANT have any ALLERGIES to medication/food? YesNo
If yes, please list those allergies to medication/food: None
Health, medical, or related physical handicap issues?
Please list medications taken regularly: None
Does the Applicant know his/her name? YesNo
Will applicant respond if called by his/her name? YesNo
Would the Applicant attempt to or have the ability to communicate if lost or hurt? YesNo
How would he/she do this?
How would you rate the Applicant’s overall ability to communicate? PoorFairGoodExcellent
What name does the Applicant call the family member or friend with whom they have the closest emotional attachment?
Does the Applicant recognize familiar persons and faces? YesNo
Does the Applicant have a fear of people, pets / animals, noises, shouting; anything else?
Do you have any suggestions for what the First Responder/Police Officer should say to the Applicant to help keep him/her calm as the First Responder/Police Officer approaches them?
Method of Preferred Communication One (If verbal: preferred phrases, words, sounds, songs they respond to):
Method of Preferred Communication Two (If nonverbal: Sign Language, written words, picture boards, etc.):
How will the Applicant react if approached by a uniformed officer?
Can the Applicant travel on his/her own to familiar or favorite locations? YesNo
List favorite attractions or locations where the Applicant may be found:
Applicant’s favorite objects, music, TV shows/characters, sports teams/players, discussion topics, likes or dislikes:
Items applicant would carry/wear that provide comfort or may have a sentimental value (Example: photos, cell phone, book, favorite hat, watch, jewelry or other object that provides comfort to them.)
Explain:
When outside, would the Applicant mostly stay on roadways? YesNo
Does the Applicant drive a car? YesNo
If so, what is the:
Would the Applicant wander to parks/go into wooded areas? YesNo
Would the Applicant most likely wander during the: DayNightBoth
Please provide the names and addresses of people the Applicant may head toward: 1. 2. 3. 4.
Are there any locations that have a special or significant attraction to the Applicant? YesNo
Please list most recent locations:
If there were any prior instances of wandering, where was the Applicant found?: Location:
General Demeanor: OutgoingQuiet
Talks to strangers: YesNo
Identification Information. (Does the Applicant carry or wear jewelry, tags, ID card, medical alert bracelets, etc?): Please explain:
Tracking Information (Does the Applicant have a Project Lifesaver number or other tracking device number?): YesNo If yes, please enter the Project Lifesaver ID number or other tracking device number:
I, the undersigned, for myself and on behalf of the Applicant named above, do hereby authorize the Hopatcong Police Department to release the above information in response to emergency calls regarding the Applicant and do further agree to indemnify and hold harmless the Hopatcong Police Department, Safely Back Home, and its respective employees, agents, officers and directors from any and all claims (other than willful misconduct) arising out of participation in the Hopatcong Police Department Safely Back Home program or the release of the above information.
Furthermore, I hereby represent and warrant to the Hopatcong Police Department and Safely Back Home that I have full power and authority, as the duly authorized representative of the Applicant named above, to enroll and act on his or her behalf.
Authorized Representative Signature (Typed)
Date:
