Senior Care Registration Form

Senior Care & Safety Check

Senior Care & Safety Check is a telephone reassurance program. This service is designed to assist the needs of Garland County Senior Citizens, disabled persons and other homebound residents that live alone and need to be checked on a daily basis.

To enroll in this free service, please complete this application and submit it to the Sheriff's Department. We will contact you and confirm the information prior to your activation in the system. Your information will be kept confidential and will not be used for purposes other than the Senior Care & Safety Check.

*Name:
*Address:
*Home Phone #:	*This is the number we will call each day
*Email:

Tell us what time of day you wish to be called This will include weekends and holidays
Call Between:		and

Do you have pets?		Do they bite?

Emergency Contact Information (Please provide (2) two contacts)

Name:
Phone #		Relationship:
Does this person have a key to your house?

Name:
Phone:		Relationship:
Does this person have a key to your house?

* = Required Fields