2. LaSalle County Sheriff's Office
   Senior Check-In Program Application
   Subscriber Information

6. Name
7. Date of Birth
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
16. Cell Number
18. Preferred Call Day of the Week
19. Preferred Call Time
23. Does your home have an alarm?

    1. YES

    1. NO
24. Police or Medical?
26. Company's Name
27. Company's Phone Number
28. Alarm Code
30. Do you have pets?

    1. YES

    1. NO
31. If yes, what type of animal(s)?
35. Is there a hidden key to your home?

    1. YES

    1. NO
36. Key Location
38. Do you have a code to access your residence or attached garage?

    1. YES

    1. NO
39. Access Code Location
40. Access Code
42. If you are unable to answer your door, what is the best way for police/medical to gain entry to your residence, if not listed above?
46. Vehicle Info - Year
47. Vehicle Make
48. Vehicle Model
50. Vehicle Color
51. License Plate Number
52. License Plate State
56. Medical Condition(s)
58. Where is your medications list kept?
60. List physical impairments, if any

64. Emergency Contacts (family or friend that can check on you if needed)

66. Name
67. Relationship to Applicant
69. Address
71. City
72. State
73. Zip Code
75. Phone Number
76. Cell Number
77. Work Number
79. Does this person have a key to your home?

    1. YES

    1. NO
81. Name
82. Relationship to Applicant
84. Address
86. City
87. State
88. Zip Code
90. Phone Number
91. Cell Number
92. Work Number
94. Does this person have a key to your home?

    1. YES

    1. NO
96. Notes/Comments

100. WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

102. The undersigned Subscriber, in consideration of being permitted to participate in the LaSalle County Sheriff’s Office Senior Check-In Program, does hereby RELEASE, WAIVE, DISCHARGE, COVENANT NOT TO SUE AND HOLD HARMLESS the County of LaSalle and the LaSalle County Sheriff and their officers, employees, all other police agencies acting in conjunction, successors and agents, from liability and any and all claims related to my participation in the LaSalle County Sheriff’s Office Senior Check-In Program including, but not limited to, any claim for direct, incidental, or consequential damage arising from the act or omission of the LaSalle County Sheriff’s Office, its volunteers, agencies, or employees in connection with the LaSalle County Sheriff’s Office Senior Check-In Program. Subscriber acknowledges that the LaSalle County Sheriff’s Office Senior Check-In Program is a public service provided at no cost to Subscriber and that the LaSalle County Sheriff’s Office, at its sole discretion may terminate this service at any time with or without notice to subscriber and/or Subscriber’s emergency contacts. Subscriber also acknowledges that technical problems or human error may result in a failure of the service at any time. In consideration of these factors, Subscriber does execute this WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT. This WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT shall be binding on the heirs, assigns, executors and administrators of subscriber.
     
     

104. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
106. Electronic Signature
107. Date of Signature
Leave This Blank:


109. 1. Receive an email copy of this form.
110. Email address

     This field is not part of the form submission.

111. Submit

* indicates a required field