Blue Angel Program Application

This safety program aims to aid older adults who are either over 55 years of age or have a medical condition that is potentially incapacitating and either live alone or alone on a frequent basis. Blue Angel Program gives emergency services quick access to a residence if the resident is unable to open the door.

*Required: ONLY for adults applying due to a medical condition. A Physician Confirmation form is required to be completed and signed by a physician before the Blue Angel Program application can be submitted. To apply, you must:

Download Physician Confirmation form
Have a physician complete and sign the form.
Complete this online application. Note: You will be required to upload the completed Physician Confirmation form below.

Need Assistance? Contact the Office of Community Engagement by:
Phone 336-373-2636 or Email communityengagement@greensboro-nc.gov.

Anyone who submits a form should be aware that in accordance with the North Carolina Public Records law, found in North Carolina General Statutes Chapter 132, their e-mail address is considered public record.

Name*

First NameMILast Name

Address*

Street Address

Apartment/Unit #

CityState

Zip Code

Phone Number*

Area CodePhone Number

Email*

Select reason for application*

I am 55 years of age or older and either live alone or am home alone on a frequent basisI have a medical condition that is potentially incapacitating and either live alone or am home alone on a frequent basis (Additional form required-see Medical Information section below for further)

Did you have a physician complete and sign the Physician Confirmation form?*

YesNo

REQUIREMENT

A Physician Confirmation form is required to be completed and signed by a physician before the Blue Angel Program application can be submitted. You must:

Download Physician Confirmation form
Have a physician complete and sign the form.
Complete this online application. Note: You will be required to upload the completed Physician Confirmation form.

Need assistance? Contact the Office of Community Engagement by:
Phone 336-373-2636 or Email communityengagement@greensboro-nc.gov.

Doctor's name*

Doctor's phone*

Area CodePhone Number

Upload the completed/signed Physician Confirmation form.*

Browse Files

Select type of pet(s)*

Dog(s)Cat(s)None

How many dogs?*

Type of breed(s)*

How many cats?*

Blue Angel Program Liability Waiver

Download Liability Waiver

LIABILITY RELEASE:
In consideration of my participation in The Greensboro Police Department’s Blue Angel Program, the undersigned, to the fullest extent permitted by law, hereby agrees for the undersigned and the undersigned’s heirs and representatives, to release, indemnify and hold harmless the Greensboro Police Department, Guilford County (including but not limited to Guilford County Emergency Medical Services), and their respective employees, officers, and attorneys from and against any and all claims, suits, judgments, losses, damages, personal injuries (including but not limited to death), or liability (including reasonable attorney’s fees), directly or indirectly arising from or in connection with the undersigned’s participation in the Greensboro Police Department’s Blue Angel Program. The undersigned acknowledges and agrees that the undersigned’s participation in the Greensboro Police Department’s Blue Angel Program is voluntary and that said program is being offered only as a courtesy. I also understand and agree the Greensboro Police Department’s Blue Angel Program is not intended in any way whatsoever to create or impose a special duty on the Greensboro Police Department, Guilford County (including but not limited to Guilford County Emergency Medical Services), and their respective employees, officers, and attorneys regarding the undersigned’s safety or well-being.
CONDITIONS:
Under the Greensboro Police Department’s Blue Angel Program, the undersigned has voluntarily agreed to participate in the program and assumes full responsibility for providing the correct key at all times. Once the lock box is installed, emergency personnel can only use the lock box to gain access to the undersigned’s home after being summoned to the home for emergency purposes. In the event of a time sensitive situation (i.e. medical emergency, fire, home invasion, etc.) or malfunction of the lock box, emergency personnel may not be able to, nor have the time to, use the lock box system. In those situation, the undersigned agrees that emergency personnel shall have the right to exercise their discretion and gain entry to the undersigned’s home by the fastest means possible. However, emergency personnel will use their best efforts to utilize the lock box when time and the situation permits.
I UNDERSTAND THE GREENSBORO POLICE DEPARTMENT’S BLUE ANGEL PROGRAM IS NOT A “LOCK OUT SERVICE” FOR ME, MY FAMILY OR MY FRIENDS. ONLY EMERGENCY PERSONNEL AND ACTUAL PARTICIPANTS WILL BE GRANTED ACCESS AND EXCESSIVE REQUESTS FOR NON-EMERGENCY ACCESS WILL RESULT IN TERMINATION OF MY PARTICIPATION IN THE GREENSBORO POLICE DEPARTMENT’S BLUE ANGEL PROGRAM AND WILL RESULT IN REMOVAL OF THE LOCK BOX.

First Name* Last Name*

Participant Signature* Date*

Blue Angel Program Application

Applicant Information

Medical Information

Pet Information

Liability Waiver