Lancaster County Keepsafe Registration
Enroll in our program by completing the form below.
Personal Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Mailing Address
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
Time to call
Please Select
7AM
7PM
7AM & 7PM
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Medical Information
Medical Conditions
List ALL physical and neurological conditions
Medications
List ALL medications you are taking
Primary Physician
Primary Physician's Phone Number
Do you have a DNR? (Do Not Resuscitate)
Please Select
YES
NO
If yes, DNR location in your home
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Keyholder & Property Information
Key location at the home
If you have keyless entry or a lockbox enter your access code
Keyholder
List a neighbor or anyone living close by who has a key to your home
Keyholder
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Would you like LCSO to have a copy of your key?
*
Please Select
YES
NO
Vehicle - List all vehicles that are in your driveway or garage. If more than one vehicle, please enter the other vehicles information into the "Other Information" box
Make
Model
Vehicle Color
License Plate
Animals - List all the animals in your home
Special Instructions before entering your home
Other
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Emergency Contacts
Emergency Contact 1
First Name
Last Name
Phone Number
Relationship
Emergency Contact 2
First Name
Last Name
Phone Number
Relationship
Emergency Contact 3
First Name
Last Name
Phone Number
Relationship
Is there anyone else you would like us to contact with any special instructions?
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Programs
I ONLY want to enroll in the daily phone check-ins
I am also interested in
Visitations
Safety & Security
Extreme Weather Preparedness
Social Hour Gatherings
Game Afternoons/ Evening
Summer Concerts
Scam Prevention
Food Assistance
Medical Transportation
What is next?
Once we received your registration we will contact you by phone to set up a day and time for a deputy or communications officer to visit with you. This person will explain the program details and answer any questions you may have. If you do not wish for an initial in-person visit, just decline it when we call you.
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