Waiver
Subscriber acknowledges that the Highland County Sheriff's Office/Regional Community Policing Institute are providing the service as a public service and for no compensation. Subscriber recognizes Highland County Sheriff's Office/Regional Community Policing Institute may, in their sole discretion, terminate this service at any time. Subscribe acknowledges that technical problems or human error may result in a failure of the service at any time. In consideration of these factors, SUBSCRIBER HEREBY WAIVES, RELEASES, AND HOLDS HARMLESS THE Highland County Sheriff's Office/Regional Community Policing Institute 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 Highland County Sheriff's Office/Regional Community Policing Institute AGAINST ANY CLAIM FOR DIRECT, INCIDENTAL, OR CONSEQUENTIAL DAMAGES ARISING FROM ANY ACT OR OMISSION OF THE Highland County Sheriff's Office/Regional Community Policing Institute, THEIR EMPLOYEES OR VOLUNTEERS, IN CONNECTION WITH THE Highland County Sheriff's Office/Regional Community Policing Institute PARTICIPATION IN THIS PROGRAM.
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Date Subscriber's Signature
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Date Subscriber's Signature
|
Are You O.K.? Field Interview Form |
| Phone Number
( ) |
Date
|
Time to
Call
Service #
:00 AM PM |
| Subscriber Name and Address
Full Name: __________________________________ Street Address: ____________________________________ __________________________________________ |
Doctor and Clergy
Doctor's Name: __________________________________ Doctor's Phone: _________________________________ Clergy Name: ___________________________________ Clergy Phone: ___________________________________ |
| In Case of Emergency, Notify:
Full Name: __________________________________ Street Address: ______________________________ __________________________________________ Phone No: _________________________________ |
Full Name:
__________________________________
Street Address: ______________________________ __________________________________________ Phone No: _________________________________ |
| Key on Premises: YES: ______ NO: ______ | Location: ___________________________________ |
| Keyholder
Full Name: ________________________________________ Street Address: ____________________________________ ________________________________________________ Phone No: _______________________________________ |
Full Name:
________________________________________
Street Address: ____________________________________ ________________________________________________ Phone No: _______________________________________ |
| Pets? YES ___ NO ___ Type: _____________ | Location: _____________________________ |
| Live Alone? YES _____ NO _____ | Co-resident: ___________________________ |
| Able to walk? YES ____ NO ____
List Physical Impairments: ____________________________________________________________________________ Location of Medical History:________________________________________________________ Other Remarks: ____________________________________________________________________________________ |