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.

 

_______________                                ____________________________________

Date                                                        Subscriber's Signature

_______________                                ____________________________________

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: ____________________________________________________________________________________