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2. Welfare Check

   If you know a senior citizen who will benefit from a welfare check from our police department, please fill out this form.

4. Name of Senior*
6. Email of Senior*
7. Confirm Email*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Neighborhood (Contract Area)*
16. Date of Birth*
    Date of Birth
17. Age*
19. Name of Emergency Contact*
20. Emergency Contact Phone*
22. Registering Someone Else?

    If you are registering someone for the Are You Ok? program, you must fill in your own information below.

24. Name*
26. Phone*
27. Alternate Phone
29. Email*
30. Confirm Email*
32. Relationship to the senior you are registering:*
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field