EmailMeForm
R U OK? Program - Application
*You must complete all fields and sign form to be eligible for the R U OK? Program.
Name
*
First
MI
Last
Date Of Birth
*
MM
/
DD
/
YYYY
Mobile Phone
###
-
###
-
####
Home Phone
###
-
###
-
####
Email Address
*
Home Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Are you able to walk without assistance?
*
Yes
No
Other (Specify if you use a cane or walker)
Do you live alone?
*
Yes
No
Is there a house key on premises?
*
Yes
No
Specify location if you would like Police Dept. to use in emergency case
Do you have pets at the residence?
*
Yes
No
If yes to the above, are they inside or outside pets?
Yes
No
Both
Are the pets harmful?
Yes
No
Please list any impairments you have:
(Hearing, sight, etc.)
Medical history:
(heart attack, stroke, diabetes, surgeries, etc.)
Primary Physician - Name & Office
Primary Physican - Phone #
Clergy - Name
Clergy - Phone #
Other Emergency Contacts
Name
Phone Number
Relationship
Contact #1
Contact #2
Preferred Call Time
HH
:
MM
AM
PM
AM/PM
Available from 7:30 AM to 4:00 PM (Monday - Friday)
Signature
Clear
Digitally sign this form above (First, middle initial, last)
