First Name:
Last Name:
Phone Number:
E-Mail Address:
Address 1:
Address 2:
City:
Zip Code:
Emergency Contact Information
Emergency Contact:
Emergency Contact Phone Number:
Emergency Contact Relationship to Senior:
Emergency Contact 2 Information
Emergency Contact 2:
Emergency Contact 2 Phone Number:
Emergency Contact 2 Relationship to Senior:
Well Being Check Preferences. Select 'Yes' to all that apply.
Extreme Heat:
-- Select --
Yes
No
Extreme Cold:
-- Select --
Yes
No
Storms or Power Outages:
-- Select --
Yes
No
General Wellness Check:
-- Select --
Yes
No
I give permission for the Sheriff's Department to contact me for wellness checks during extreme weather or emergencies. This service is free and meant to help keep me safe.