Form Builder

Today's Date

Date of Birth

First Name

Middle Initial

Last Name

Phone Number

Voicemail?

Full Address

Street Address

Street Address 2

City

State

Zip

Impairements

Able to walk?

Lives Alone?

Key on Premises?

Has Pets?

Comments

Doctor's Name

Doctor's Phone Number

Clergy's Name

Clergy's Phone Number

Emergency Contact Information

Emergency Contact's First Name

Emergency Contact's Last Name

Emergency Contact's Home Phone Number

Emergency Contact's Work Phone Number

Emergency Contact's Cell Number

Emergency Contact's Email Address

Emergency Contact's Street Address

Emergency Contact's Street Address 2

Emergency Contact's City

Emergency Contact's State

Emergency Contact's Zip

Next of Kin Information

Next of Kin's First Name

Next of Kin's Last Name

Next of Kin's Home Phone Number

Next of Kin's Work Phone Number

Next of Kin's Cell Phone Number

Next of Kin's Emaill Address

Next of Kin's Street Address

Next of Kin's Street Address 2

Next of Kin's City

Next of Kin's State

Next of Kin's Zip

Keyholder's Information

Keyholder's First Name

Keyholder's Last Name

Keyholder's Home Phone Number

Keyholder's Work Phone Number

Keyholder's Cell Phone Number

Keyholder's Street Address

Keyholder's Street Address 2

Keyholder's City

Keyholder's State

Keyholder's Zip

Release Section

Type name below to accept release

I understand that as a participant in the Catawba County Sheriff’s Office, “Are You Okay” Program, I am authorizing any Law Enforcement Officer in my jurisdiction to enter my home to ensure that I am physically safe if they are unable to reach me by telephone. I do hereby release, absolve, indemnify and hold harmless Catawba County Sheriff’s Office and any Law Enforcement Agency responding to assist me, from any property damage that may occur as a result of them entering my home by force.

Type name below to accept release

I understand that as a participant in the Catawba County Sheriff’s Office, “Are You Okay” Program, I am not authorizing a Law Enforcement Officer to enter my home to ensure that I am physically safe if they are unable to reach me by telephone.