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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