REASON FOR APPLICATION:
I am 60 years of age or older, living alone, or am frequently left alone
I have a medical condition that is potentially incapacitating and I live alone or I am alone on a frequent basis.
PARTICIPANT INFORMATION:
*Name:
Birthdate: Height: Weight: Eye Color: Hair Color:
*Address:
Street Address City State ZIP
Phone Number:
Are there other occupants at this address? If yes, please list names and relation below:
Are there pets at this address? If yes, please list number and type below:
Vehicle information (if applicable):
License Plate State Year Make Model Color
MEDICAL INFORMATION:
*Please describe your medical condition:
*Doctor's name and phone number:
*Medications:
EMERGENCY CONTACT INFORMATION:
*Name: Relationship:
*Cell Phone: Home Phone: Work Phone:
Home Address:
Name: Relationship:
Cell Phone: Home Phone: Work Phone:
Home Address:
I hereby attest that I am authorized to provide all of the foregoing information to the Carrollton Police Department.
*Initials:
HOLD HARMLESS AND INDEMNITY:
BY PARTICIPATING IN THE SENIOR LOCKBOX PROGRAM (“PROGRAM”), I AUTHORIZE THE CARROLLTON POLICE AND FIRE DEPARTMENT TO INSTALL THE LOCKBOX ONTO MY RESIDENCE AND TO ENTER MY RESIDENCE FOR EMERGENCY PURPOSES. IN CONSIDERATION FOR MY PARTICIPATION IN AND BENEFITTING FROM THIS PROGRAM, THE RECEIPT AND SUFFICIENCY OF SUCH CONSIDERATION ARE HEREBY AFFIRMED, I HEREBY COVENANT AND CONTRACT TO RELEASE, DEFEND, INDEMNIFY AND HOLD THE CITY OF CARROLLTON, ITS OFFICERS, AGENTS, AND EMPLOYEES, IN BOTH THEIR PUBLIC AND PRIVATE CAPACITIES, HARMLESS FROM AND AGAINST ANY AND ALL CAUSES OF ACTION, CITATIONS, CLAIMS, LAWSUITS, JUDGMENTS, DAMAGES, DEMANDS, LIABILITIES, COSTS, LOSSES, PENALITIES, AND EXPENSES FOR PERSONAL INJURY (INCLUDING DEATH), PROPERTY DAMAGE, OR OTHER HARM FOR WHICH RECOVERY OF DAMAGES IS SOUGHT, SUFFERED BY ANY PERSON OR PERSONS, THAT MAY ARISE OUT OF OR IN ANY WAY RELATE TO MY PARTICIPATION IN THE PROGRAM. INDEMNIFIED ITEMS SHALL ALSO INCLUDE ANY EXPENSES, INCLUDING ATTORNEY’S FEES AND EXPENSES, INCURRED BY AN INDEMNIFIED INDIVIDUAL OR ENTITY IN ENFORCING THIS INDEMNITY.
*Printed Name: *Relationship:
*Date: *Signature: