R U OK? Program - Application
*You must complete all fields and sign form to be eligible for the R U OK? Program.
  • / /
  • - -
  • - -
  • (Hearing, sight, etc.)
  • (heart attack, stroke, diabetes, surgeries, etc.)
  • Name Phone Number Relationship
    Contact #1
    Contact #2
  • :
    Available from 7:30 AM to 4:00 PM (Monday - Friday)
  • Digitally sign this form above (First, middle initial, last)