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Department News

Wellbeing Check

Individual Information (Individual to be check)

Date

Last Name

First Name

Address

City & Zip

Home Phone

Cell Phone

Date of Birth

Gender

Race

Vehicle Make/Model

Vehicle Year

Vehicle Color

Plate Number

Vehicle Make/Model

Vehicle Year

Vehicle Color

Plate Number

Medical History

Are you/they able to walk? NoYes

List physical impartments & medical conditions

How Often to be checked on

Relative Requesting/Authorizing Wellbeing Check

Name

Home Phone

Cell Phone

Address

City & Zip

Date Request Checks to begin

Key & Residence Information

Is there a key on the premises

Key Location

Medical Alarm? Burglar Alarm? Lights on Timer(s)?

Keyholder in case of emergency

Name (Last, First, M.I.)

Relationship

Home Phone

Cell Phone

Address

City & Zip

Next of Kin

Name (Last, First, M.I.)

Relationship

Home Phone

Cell Phone

Address

City & Zip

Clergy & Doctor & Other Emergency Contact Information

Doctor's Name Phone

Clergy's Name Phone

Other Name Phone

Expiration & Renewal of Service
****Note: This service requires annual revalidation and will expire one year (1 Year) from the date signed. This request must be renewed and updated at least annually for the Are You Ok Wellbeing Check service to be provided