LW Resident Contact Information Update

Please provide us with your current contact information. Recently, volunteers made wellness calls to residents to see if they were alright and to see if they needed anything. We found many of the phone numbers we have on file did not work. We will update our Telephone Directory with your current numbers.

We also would like to update your emergency contact information and for our snowbirds, out of town dates and phone numbers as well as who has a key to your LW house (house watcher).

New questions will apprear based on answers you give.

THANK YOU

Date

DateHourMinutesAM/PM Option

Name of RESIDENT 1*

First NameLast Name

Address in Lauderdale West*

Street Address ONLY

Street Address Line 2

Status - Resident 1*

OwnerRenterOther

Landline - Resident 1

Country CodeArea CodePhone Number

Cell Phone - Resident 1

Country CodeArea CodePhone Number

The number I prefer to have listed in the LW Telephone Directory (Resident 1) is:

My landlineMy cell phoneDon't show my number in the LW Telephone Directory

Email address - Resident 1

May we update the emergency contact information for Resident 1?

YesNo

Emergency Contact Name for Resident 1?

First NameLast Name

Emergency Contact's Phone Number for Resident 1

Country CodeArea CodePhone Number

Emergency Contact's Email address - Resident 1

example@example.com

Is Resident 1 a seasonal resident (snowbird)?

YesNo

I'm usually out of town from about (Resident 1)

MonthDayYear

I usually return to Lauderdale West around (Resident 1)

MonthDayYear

Name of a local person with an emergency key (Resident 1)?

First NameLast Name

Key holder's phone number (Resident 1)

Country CodeArea CodePhone Number

Key holder's address (Resident 1)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name - RESIDENT 2

First NameLast Name

Status - Resident 2

OwnerRenterOther

Landline - Resident 2

Area CodePhone Number

Cell Phone - Resident 2

Area CodePhone Number

The number I prefer to have listed in the LW Telephone Directory (Resident 2) is:

My landlineMy cell phoneDon't show my number in the LW Telephone Directory

Email address - Resident 2

example@example.com

May we update the emergency contact information for Resident 2?

YesNo

Emergency Contact Name for person 2?

First NameLast Name

Emergency Contact's Phone Number for person 2?

Area CodePhone Number

Emergency Contact's Email address - person 2

example@example.com

Is Resident 2 a seasonal resident (snowbird)?

YesNo

Are the out of town and return dates the same as Resident #1?

YesNo

I'm usually out of town from about (Resident 2)

MonthDayYear

I usually return to Lauderdale West around (Resident 2)

MonthDayYear

Name of a local person with an emergency key (Resident 2)?

First NameLast Name

Key holder's phone number (Resident 2)

Area CodePhone Number

Key holders address (Resident 2)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-Signature - Draw the initials of the head of household. This gives us the authority to update the records of each person listed in the form. Use your mouse or finger for a touch sensitive device like a cell phone or tablet.*

THANKS for taking the time to update your information! Please update again any time your information changes. You can call the business office to make changes if you prefer. The number is 954-473-8219.

Please check the box to prove you are human*