application

East Ridge Police Community Care Program East Ridge Seniors Subscriber Information Date: ________________________ Subscriber Information Name: Date of Birth: Address: City/State/Zip: Home # In Case of Emergency, Notify Name: Relationship: Address: City/State/Zip: Home # Work # Cell/Alt # In Case of Emergency, Notify (2) Name: Relationship: Address: City/State/Zip: Home # Work # Cell/Alt # Key Location/Occupant Information Extra Key? Yes ☐ No ☐ Location: Pets? Yes ☐ No ☐ Description: Live Alone? Yes ☐ No ☐ Occupants: Life Alert? Yes ☐ No ☐ Alarm? Yes ☐ No ☐ Company? Vehicle? Yes ☐ No ☐ Details? Make: Model: Year: Color: Medical History Able to Walk? Yes ☐ No ☐ Physical Impairments: Yes ☐ No ☐ Primary Care Physician Name: Tel. #: ________ List:_______________________________________________________________ ___________________________________________________________________ Page 1 of 2 I, the undersigned, freely and voluntarily give permission to the East Ridge Police Department and/or their agents, representatives, principals, and employees, to enter my residence for the purpose of checking on the well-being of myself and/or my family. Upon the circumstance that Officers of the East Ridge Police Department reasonably believe that an emergency exists and a key holder cannot respond in time to reasonably mitigate the emergency, I agree to hold harmless the City of East Ridge for any and all damages incurred to any personal and/or real property if entry into my residence is forced. I further agree to waive any and all claims I have or may have, whether known or unknown, arising out of my voluntary enrollment into this Program. Signature Date Print Name Page 2 of 2