SCP SECURITY | SENIOR CITIZENS VIP CARE CHECK SERVICE REQUEST V2

SCP SECURITY | SENIOR CITIZENS VIP CARE CHECK SERVICE

Friendly visit to the home to check and provide a caring senior citizen service.
Friendly visit to the home to check and provide a caring senior citizen service.

Our team will visit your close family/ friend to check on their status and handle special requests. We care and understand the need to ensure that they feel cared for and know that they are not alone.
They can contact us in case of an emergency and we will maintain a log of events in our OB book and send a picture to assure you of their well-being on request.

Senior Citizen Care Solution at R149 incl. VAT per month | 15 ~ 30 Minutes per visit
Ideal if you have relocated to another suburb or town some distance away and aren't able to visit as often as you would like to, or the associated traveltime and cost of living is overwhelming.
This is an affordable subscription for a minimum 12 month period via debit order. Standard T&C's apply.

Included in the VIP CARE CHECK service:
- 15 ~ 30 Minute daily or evening visits.
- Weekly or Monthly visits can be arranged.*
- Notifying medical practitioners or family acquaintances.
- Security check - environment and alarm systems.
- Interaction with and building a trusted relationship.
- Utility services support - Load shedding schedules.
- Health checks / Emergency visits (if Necessary).*
- Switching lights and watering systems On / Off.
- Weekly refuse bin placement.
At SCP SECURITY we care for all our senior citizens in our community. To ensure we provide the best support available, individual/s will need to have any special needs identified in their Personal Profile.
Each individual will require a detailed personal health / status assessment Profile provided by the responsible family member and/or their medical practitioner to enable our accredited personnel and other healthcare specialists to attend to their personal services and needs thus ensuring a healthy home / living environment is created. We work in close cooperation with Retirement Villages and Old Age Homes where additional support may be required.

T&C's apply.*

Cancellation Policy:

Please note that you will need to confirm any cancellation with us, at least 72 hours in advance to avoid the full amount being charged and due.

Please complete the form below with as much information as possible. This will enable our team to get back to you promptly to finalise and confirm your booking.
Your Information

Please provide us with your contact information and location as the signatory for this service.
Full Name:*

TitleFirst NameLast Name
Email Address:*
example@example.com
Phone Number*

Area CodePhone Number
Relationship to VIP Senior Citizens:
Are you a client of SCP SECURITY?*

YesNo
SCP SECURITY Account No. | Client Code:
Who is your current Armed Response Provider?
What type of Property is this?

ResidentialBusiness
Company | Business Name:
Physical Address of Property:*

Street Address

Suburb | Area

CityState / Province

Postal / Zip Code
Alternative family / friend in case of unavailability:

First NameLast Name
Alternative family / friend's Phone Number:

Area CodePhone Number
Senior Citizen Location Information

This service is charged per Senior Citizen location within the service areas. If you have 1 location it will be charged at R149 incl. per month. Should you select 2 locations, you will be charged R149 + R149 = R298 incl. Vat per month. You can have more than one Senior Citizen at each location and you will be charged for the number of locations that need to be visited. You will be required to provide the Senior Citizen's profiles with visiting times for each location at the end of the form.
How many locations will you need our team to visit?*
Monthly Subscription Information

You have selected the Senior Citizens VIP Care Check Monthly Service option at R 149 incl. VAT per month per Senior Citizen location for 12 months. Please authorise the debit order below and provide banking details if necessary.
MONTHLY FEE:
The amount to be deducted from your account each month in Rands.
Required Commencement Date:

DayMonthYear
Date Subscription Requested to Start
I, The undersigned "Client", hereby instruct and authorise Suburban Control Centre (Pty) Ltd t/a SCP SECURITY, to draw against my bank account, the monthly payment of R as an addition to my existing debit order agreement. In terms of this agreement, on the 1st day of each month or as of the effective date of commencement of billing, for the minimum duration of 12 months.
ACCOUNT HOLDER:
Name of the Bank Account Holder
ACCOUNT TYPE:
Type of Bank Account - Savings, Cheque, Current
ACCOUNT NUMBER:
Number of the Bank Account
NAME OF BANK:
Name of the Bank where account is held
BRANCH NAME:
Name of the Branch where the account is held
BRANCH CODE:
Bank Branch Code
I, The undersigned "Client", hereby instruct and authorise Suburban Control Centre (Pty) Ltd t/a SCP SECURITY, to draw against my bank account, the monthly payment of R . In terms of this agreement, on the 1st day of each month or as of the effective date of commencement of billing, for the minimum duration of 12 months.
SIGNATURE:

Clear
DATE OF SIGNING:

DayMonthYear
Date this agreement was signed
VIP Senior Citizen and their Location Information

Please provide us with more details about the Senior Citizens you would like us to check in with at each location so that we can provide the best attention.
Add Senior Citizen Location 1

This is the first location to be visited. You will need to add the profiles of the VIP Senior Citizens at this location.
Address where they are to be visited:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorised Contact Person at Property:

TitleFirst NameLast Name
Designation of Authorised Contact Person:
Phone Number of Authorised Contact Person:

Area CodePhone Number
Senior Citizen 1 Profile

The individual information for Senior Citizen 1 to be visited at Location 1.
VIP Senior Citizen's Name:

Title: Mr / Mrs / Ms / MissFirst NameLast Name
VIP Senior Citizen's Phone Number:

Area CodePhone Number
Relationship to responsible Signatory:
ID Number (RSA or Other)
VIP Senior Citizen's General physical condition
Please specify any medical conditions or physical complications that might need to be taken into consideration
Doctor's Name:

TitleFirst NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact - Full Name:

TitleFirst NameLast Name
Emergency Contact - Phone Number:

Area CodePhone Number
Medical Aid Name:
Package / Option:
Medical Aid Membership Number:
Medical Aid Account Number:
Senior Citizen 2 Profile

The individual information for Senior Citizen 2 to be visited at Location 1.
Would you like to add information for a second VIP Senior Citizen at this address?

Yes PleaseNo Thanks
VIP Senior Citizen's Name

Title: Mr / Mrs / Ms / MissFirst NameLast Name
VIP Senior Citizen's Phone Number:

Area CodePhone Number
Relationship to responsible Signatory:
ID Number (RSA or Other)
VIP Senior Citizen's General physical condition
Please specify any medical conditions or physical complications that might need to be taken into consideration
Doctor's Name:

TitleFirst NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact - Full Name:

TitleFirst NameLast Name
Emergency Contact - Phone Number:

Area CodePhone Number
Medical Aid Name:
Package / Option:
Medical Aid Membership Number:
Medical Aid Account Number:
Senior Citizen 3 Profile

The individual information for Senior Citizen 3 to be visited at Location 1.
Would you like to add information for a third VIP Senior Citizen at this address?

Yes PleaseNo Thanks
VIP Senior Citizen's Name

Title: Mr / Mrs / Ms / MissFirst NameLast Name
VIP Senior Citizen's Phone Number:

Area CodePhone Number
Relationship to responsible Signatory:
ID Number (RSA or Other)
VIP Senior Citizen's General physical condition
Please specify any medical conditions or physical complications that might need to be taken into consideration
Doctor's Name:

TitleFirst NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact - Full Name:

TitleFirst NameLast Name
Emergency Contact - Phone Number:

Area CodePhone Number
Medical Aid Name:
Package / Option:
Medical Aid Membership Number:
Medical Aid Account Number:
Senior Citizen Location 1 | Visit Dates and Times

Please let us know when is best to visit Location 1.
Do you require one or two visits a day?*

Once a dayTwice a day
Will you require visits every day?*

Yes, please visit every day.Not thanks, please visit every second day.No thanks, please visit on specific days I select.
Date and Time of First Visit:*

DayMonthYear
DateHourMinutesAM/PM Option
What are the preferred times you would like our team to visit? (We will try our best to visit as close to these times as possible)
Individual Dates and Times Preferred: (If each day is different)
Special notes or comments:
Any other notes or information that will help us to prepare for the service.
Add Senior Citizen Location 2

This is the second location to be visited. You will need to add the profiles of the VIP Senior Citizens at this location.
Address where they are to be visited:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorised Contact Person at Property:

TitleFirst NameLast Name
Designation of Authorised Contact Person:
Phone Number of Authorised Contact Person:

Area CodePhone Number
Senior Citizen 1 Profile

The individual information for Senior Citizen 1 to be visited at Location 2.
VIP Senior Citizen's Name:

Title: Mr / Mrs / Ms / MissFirst NameLast Name
VIP Senior Citizen's Phone Number:

Area CodePhone Number
Relationship to responsible Signatory:
ID Number (RSA or Other)
VIP Senior Citizen's General physical condition
Please specify any medical conditions or physical complications that might need to be taken into consideration
Doctor's Name:

TitleFirst NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact - Full Name:

TitleFirst NameLast Name
Emergency Contact - Phone Number:

Area CodePhone Number
Medical Aid Name:
Package / Option:
Medical Aid Membership Number:
Medical Aid Account Number:
Senior Citizen 2 Profile

The individual information for Senior Citizen 2 to be visited at Location 2.
Would you like to add information for a second VIP Senior Citizen at this address?

Yes PleaseNo Thanks
VIP Senior Citizen's Name

Title: Mr / Mrs / Ms / MissFirst NameLast Name
VIP Senior Citizen's Phone Number:

Area CodePhone Number
Relationship to responsible Signatory:
ID Number (RSA or Other)
VIP Senior Citizen's General physical condition
Please specify any medical conditions or physical complications that might need to be taken into consideration
Doctor's Name:

TitleFirst NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact - Full Name:

TitleFirst NameLast Name
Emergency Contact - Phone Number:

Area CodePhone Number
Medical Aid Name:
Package / Option:
Medical Aid Membership Number:
Medical Aid Account Number:
Senior Citizen 3 Profile

The individual information for Senior Citizen 3 to be visited at Location 2.
Would you like to add information for a third VIP Senior Citizen at this address?

Yes PleaseNo Thanks
VIP Senior Citizen's Name

Title: Mr / Mrs / Ms / MissFirst NameLast Name
VIP Senior Citizen's Phone Number:

Area CodePhone Number
Relationship to responsible Signatory:
ID Number (RSA or Other)
VIP Senior Citizen's General physical condition
Please specify any medical conditions or physical complications that might need to be taken into consideration
Doctor's Name:

TitleFirst NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact - Full Name:

TitleFirst NameLast Name
Emergency Contact - Phone Number:

Area CodePhone Number
Medical Aid Name:
Package / Option:
Medical Aid Membership Number:
Medical Aid Account Number:
Senior Citizen Location 2 | Visit Dates and Times

Please let us know when is best to visit Location 2.
Do you require one or two visits a day?*

Once a dayTwice a day
Will you require visits every day?*

Yes, please visit every day.Not thanks, please visit every second day.No thanks, please visit on specific days I select.
Date and Time of First Visit:*

DayMonthYear
DateHourMinutesAM/PM Option
What are the preferred times you would like our team to visit? (We will try our best to visit as close to these times as possible)
Individual Dates and Times Preferred: (If each day is different)
Special notes or comments:
Any other notes or information that will help us to prepare for the service.
Disclaimer:

SCP SECURITY will monitor and ensure that the services and conditions as agreed to in the SENIOR CITIZENS VIP CARE CHECK agreement are complied with to the best of our abilities.

Any special instructions or requests must be sent in writing to yasmine@scpsecurity.co.za for approval, and where practical, inclusion into the standard list of services provided.

The service is charged by number of locations to be visited. The service is only offered in areas in which SCP SECURITY operates.

Special additional services, over and above those set out in the agreement, may be offered (on prior approval by the signatory) to ensure the most efficient and suitable care is provided during the responsible performance of our duties.

Cancellation period should be within 72 hours by either party with notification provided in writing as this must be handled with due care and consideration of the family’s legal and emotional needs. The balance of outstanding fees due for the period as at the date of notification will remain due until the debit order is confirmed as cancelled.

E&OE and T&C’s apply
SERVICE AGREEMENT forming part of the SCP Security Standard Agreement and Terms & Conditions.
Signature of Responsible Signatory:*

Clear
Date of Signature:

MonthDayYear
Date
Should be Empty:

SCP SECURITY | SENIOR CITIZENS VIP CARE CHECK SERVICE

Your Information

Senior Citizen Location Information

Monthly Subscription Information

VIP Senior Citizen and their Location Information

Add Senior Citizen Location 1

Senior Citizen 1 Profile

Senior Citizen 2 Profile

Senior Citizen 3 Profile

Senior Citizen Location 1 | Visit Dates and Times

Add Senior Citizen Location 2

Senior Citizen 1 Profile

Senior Citizen 2 Profile

Senior Citizen 3 Profile

Senior Citizen Location 2 | Visit Dates and Times