SafeGuardian Subscriber Information Form

Please Select Type of Update

Register New AccountModify 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*

Postal (Zip) Code:*

Email Address (if applicable):

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Subscriber Date of Birth

Date

Location Of Hidden House Key Or Lock Box:

Key Lock Box or House/Garage Keypad Combination:

Blood Type (if known):

Current Medical Conditions:

Required Medications:

Location of Medications In the Home:

Known Allergies:

Special Instructions/DNR's/POA:

Preferred Hospital:

Hard of Hearing?

YesNo

Poor Vision?

YesNo

Speaks English?

YesNo

Contact #1 Name:

Contact #1 Relationship:

Contact #1 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Contact #1 Primary Phone Type:

Contact #1 Email Address

Contact Has House Key?

YesNo

Contact #2 Name:

Contact #2 Relationship:

Contact #2 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Contact #2 Primary Phone Type:

Contact #2 Email Address

Contact Has House Keys?

YesNo

Contact #3 Name:

Contact #3 Relationship:

Contact #3 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Contact #3 Primary Phone Type:

Contact #3 Email Address

Contact Has House Keys?

YesNo

Contact #4 Name:

Contact #4 Relationship:

Contact #4 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Contact #4 Primary Phone Type:

Contact #4 Email Address

Contact Has House Keys?

YesNo

I accept the Terms and Conditions of the SafeGuardian Service Agreement*

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 NameLast Name

Submitted By Email Address:

Relationship To Subscriber:

SafeGuardian Subscriber Information Form

Section 1: Subscriber Information