SafeGuardian Subscriber Information Form
Complete & Submit this form to register and update your SafeGuardian Help Alert Monitoring Account anytime. The red asterisks indicate required fields.
Section 1: Subscriber Information
Please Select Type of Update
Register New Account
Modify Existing Account
SafeGuardian Account Number (if available):
Subscriber First Name:
*
Subscriber Last Name:
*
Physical Home (Street) Address:
*
Apartment, Space or Unit Number (if applicable):
City:
*
State
*
Please Select
Alabama - AL
Alaska - AK
Arizona - AZ
Arkansas - AR
California - CA
Colorado - CO
Connecticut - CT
Delaware - DE
Florida - FL
Georgia - GA
Hawaii - HI
Idaho - ID
Illinois - IL
Indiana - IN
Iowa - IA
Kansas - KS
Kentucky - KY
Louisiana - LA
Maine - ME
Maryland - MD
Massachusetts - MA
Michigan - MI
Minnesota - MN
Mississippi - MS
Missouri - MO
Montana - MT
Nebraska - NE
Nevada - NV
New Hampshire - NH
New Jersey - NJ
New Mexico - NM
New York - NY
North Carolina - NC
North Dakota - ND
Ohio - OH
Oklahoma - OK
Oregon - OR
Pennsylvania - PA
Rhode Island - RI
South Carolina - SC
South Dakota - SD
Tennessee - TN
Texas - TX
Utah - UT
Vermont - VT
Virginia - VA
Washington - WA
West Virginia - WV
Wisconsin - WI
Wyoming - WY
Postal (Zip) Code:
*
Email Address (if applicable):
Phone Number
Please enter a valid phone number.
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Location Of Hidden House Key Or Lock Box:
Key Lock Box or House/Garage Keypad Combination:
Blood Type (if known):
Please Select
Unknown
"O" Positive
"O" Negative
"A" Positive
"A" Negative
"B" Positive
"B" Negative
"AB" Positive
"AB" Negative
Current Medical Conditions:
Required Medications:
Location of Medications In the Home:
Known Allergies:
Special Instructions/DNR's/POA:
Preferred Hospital:
Hard of Hearing?
Yes
No
Poor Vision?
Yes
No
Speaks English?
Yes
No
Contact #1 Name:
Contact #1 Relationship:
Please Select
Immediate Family
Caregiver
Friend/Neighbor
Contact #1 Phone
Please enter a valid phone number.
Contact #1 Primary Phone Type:
Please Select
Cell/Mobile Phone
Home Phone
Office/Work Phone
Contact #1 Email Address
Contact Has House Key?
Yes
No
Contact #2 Name:
Contact #2 Relationship:
Please Select
Immediate Family
Caregiver
Friend/Neighbor
Contact #2 Phone
Please enter a valid phone number.
Contact #2 Primary Phone Type:
Please Select
Cell/Mobile Phone
Home Phone
Office/Work Phone
Contact #2 Email Address
Contact Has House Keys?
Yes
No
Contact #3 Name:
Contact #3 Relationship:
Please Select
Immediate Family
Caregiver
Friend/Neighbor
Contact #3 Phone
Please enter a valid phone number.
Contact #3 Primary Phone Type:
Please Select
Cell/Mobile Phone
Home Phone
Office/Work Phone
Contact #3 Email Address
Contact Has House Keys?
Yes
No
Contact #4 Name:
Contact #4 Relationship:
Please Select
Immediate Family
Caregiver
Friend/Neighbor
Contact #4 Phone
Please enter a valid phone number.
Contact #4 Primary Phone Type:
Please Select
Cell/Mobile Phone
Home Phone
Office/Work Phone
Contact #4 Email Address
Contact Has House Keys?
Yes
No
I accept the Terms and Conditions of the SafeGuardian Service Agreement
*
Please Select
I Accept
BY SIGNING THIS AGREEMENT, YOU (I) UNDERSTAND THAT THIS IS A BINDING AGREEMENT AND INCLUDE THE TERMS AND CONDITIONS ON THE REVERSE; (II) ACCEPT THE DISCLAIMER/LIMITATION OF LIABILITY AND INDEMNITY PARAGRAPHS OF THIS AGREEMENT; AND (III) ACKNOWLEDGE HAVING RECEIVED AND READ A COPY OF THE ENTIRE AGREEMENT BEFORE SIGNING. USE OF THE SYSTEM CONSTITUTES ACCEPTANCE OF THE TERMS AND CONDITIONS OF THIS AGREEMENT, INCLUDING THE LIMITATION OF LIABILITY, INDEMNITY AND OTHER RISK ALLOCATION CLAUSES CONTAINED IN THIS AGREEMENT. Subscriber and/or Payee hereby authorizes SafeGuardian, LLC, or its assignee Alarm Billing Services, to commence ongoing automatically recurring electronic debits from my credit card or bank account for all amounts owed under this Service Agreement based upon the service billing plan (monthly, quarterly or annually) I have selected in writing. I understand that this authorization will remain in effect until I cancel it, in advance, in writing. I agree to notify SafeGuardian, LLC, in writing of termination of this authorization at least seven (7) days prior to the next scheduled billing date. I understand and accept that the pre-paid monitoring service plan I have chosen is non-refundable for the next service period once charged. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions, processed in accordance to the terms indicated in this Monitoring Service Agreement, occurred prior to delivery of my written cancellation notice.
Submitted by Name:
First Name
Last Name
Submitted By Email Address:
Relationship To Subscriber:
Submit
Should be Empty: