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Senior Check-In Form

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

  2. Does your home have an alarm?
  3. Do you have pets?
  4. Is there a hidden key to your home?
  5. Do you have a code to access your residence or attached garage?
  6. Emergency Contacts (family or friend that can check on you if needed)

  7. Does this person have a key to your home?
  8. Does this person have a key to your home?
  9. WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

  10. 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.

  11. 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.
  12. Leave This Blank:

  13. This field is not part of the form submission.