(Confidential) The River Watch: Program Sign-Up Form

1. Participant Information

Full Name *

Date of Birth *

Address

Street Address *

Country

State

City

Postal Code

Phone *

Landline Phone (if applicable)

Preferred Method of Contact *

Telephone Call

Text Message

2. Emergency Contact Details

Please provide a contact who lives close to you that you are comfortable in granting access to your home. (PLEASE NOTE: IN ORDER TO PARTICIPATE IN THIS PROGRAM, YOU MUST HAVE AN EMERGENCY CONTACT LISTED! NEIGHBOR, FRIEND, FAMILY MEMBER, ETC.)

Primary Emergency Contact Name *

Relationship *

Phone Number of Contact *

Preferred Method of Contact to Emergency Contact *

Telephone Call

Text Message

Does this person have a key to your home? (Highly Recommended) *

Yes

No

3. Medical & Safety Information

Health Conditions/Concerns *

Mobility Assistance Needed? (e.g. walker, wheelchair) *

Yes

No

Are there pets in the home? *

Yes

No

If yes, what type of pets?

Are you on any in home services? (e.g. Home Health/Hospice) *

Yes

No

If yes, provide the Company Name

If yes, provide the Company Phone Number

4. Terms and Consent

By signing below, I confirm that the information provided is accurate and that I have read and signed the "River Watch Participant Consent & Liability Waiver." I understand that this program is a voluntary wellness check and not an emergency medical service.

Signature *

Clear

Date *

Participant Consent & Liability Waiver

PARTICIPANT ENROLLMENT: I have read and fully understand the Participant Consent & Liability Waiver for The River Watch program. By checking this box, I acknowledge my agreement and consent to these terms. This action serves as my electronic signature. I acknowledge that I am participating voluntarily and agree to all terms, including the waiver and release of liability, and understand that I am giving up certain legal rights, including the right to sue. *

By checking this box, I acknowledge my agreement and consent to these terms. This action serves as my electronic signature.

THIRD PARTY ENROLLMENT: I am completing this form and signing the Participant Consent & Liability Waiver for Participant at the participant’s request. The participant personally gave me permission to enroll them in The River Watch program and to sign this waiver on their behalf. I have reviewed or explained the waiver and program terms with the participant, including the daily call or text and the notification of the listed emergency contact by call or text if the participant does not respond. The participant told me that they understand these terms, voluntarily agree to participate, and want me to sign the waiver for them. I am signing in a representative capacity for the participant, based on the participant’s authorization. I am not signing in my personal capacity.

By checking this box, I electronically sign the Participant Consent & Liability Waiver on behalf of Participant, as their expressly authorized representative and I confirm the statements above are true.

Third Party Contact Information (IF APPLICABLE)