Charlton County 911 RUOK Program

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Best day / days to call you each week*

Enter day / days of the week

Best time of day to call you each week*

Enter time of day

Phone Number for us to call each week*

Format: (000) 000-0000.

Contact Name in event of emergency*

First NameMiddle NameLast Name

Emergency Contact Mobile Number*

Format: (000) 000-0000.

Emergency Contact Phone Number

Format: (000) 000-0000.

Is there a house key on premises we can use to gain entry in case of emergency?*

YESNO

If YES, Where is key located?

Is there anyone we can call who has a key to your home in case of emergency?*

YESNO

If YES enter contact Name

First NameMiddle NameLast Name

If YES enter Phone Number

Format: (000) 000-0000.

Do you have any pets?*

YESNO

If YES, What type of pet?

Do you live alone?*

YESNO

If NO, list co-resident full name.

Are you able to walk?*

YESNO

If NO, list any physical or medical impairments.

Enter impairments

Are you taking medications*

YESNO

If YES, list any medications.

Enter medications

Any Remarks or Comments

Waiver Clause

“WAIVER” RELEASE AND HOLD HARMLESS THE CHARLTON COUNTY SHERIFF’S OFFICE  AND CHARLTON COUNTY 911  CENTER AGAINST ANY CLAIM IN RELATION TO SERVICE RECEIVED THROUGH THE R.U.O.K. PROGRAM.
Subscriber acknowledges that the Charlton County Sheriff’s Office and Charlton County 911 Center are providing this service as a service and for no compensation. Subscriber recognizes that the Charlton County Sheriff’s Office and Charlton County 911 Center may, in their sole discretion, terminate this service at any time. In consideration of these factors, subscriber hereby waives, releases and hold harmless the Charlton County Sheriff’s Office and Charlton County 911 Center from any claim arising from a failure, for any reason, to provide the services contemplated by this agreement, and subscriber further agrees to waive, release and hold harmless the Charlton County Sheriff’s Office and Charlton County 911 Center against any claim for direct, incidental, or consequential damages arising from any action or omission of the Charlton County Sheriff’s Office and Charlton County 911 Center, their volunteers and/or employees, in connections with the Charlton County Sheriff’s Office and Charlton County 911 Center participating in this program.

By submitting this form the subscriber acknowledges and agrees to this Hold Harmless Waiver clause.

If at anytime you wish to be removed from or suspend the Charlton County 911 RUOK Program please contact 911 at the non-emergency number (912) 496-7321.

Thank You for allowing us to serve you!

Charlton County 911 R.U.O.K.