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

1. Participant Information

Full Name

Age

Address

Street Address

City

State

Country

Enter your country

Postal Code

Phone *

Landline Phone (if applicable)

Preferred Method of Contact *

Landline

Cellphone

Email

2. Emergency Contact Details

Please provide a contact who lives close to you that you are comfortable in granting access to your home.

Primary Emergency Contact Name

Relationship

Phone Number of Contact

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

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

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Date

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