Forms • Jacksonville, NC • CivicEngage

Jacksonville Public Safety's CARE program is designed for elderly, disabled persons, shut-ins who live alone, or anyone in the community who needs to be checked upon daily.

CARE is a computerized telephone calling system, providing a daily checkup on the subscriber. The subscriber will choose a time the system will call for their daily reassurance check. The calls will always be made in the same order, so the subscriber will quickly learn exactly when to expect their call. When the subscriber picks up the telephone, a recorded message will play. If the subscriber fails to answer the phone after several attempts, or if there is a busy signal several times in a row, the computer will immediately notify the 911 Center. The 911 Center will then input a call for service and have a patrol unit check on the subscriber.

During holidays, vacations, or any other times the subscriber plans to not receive the daily call, a simple call to the 911 Center, 910-455-4000 or 910-455-1472, will stop the daily call for the requested length of time.

There is absolutely NO CHARGE of any kind for this service.

It is important to understand the CARE program is not intended to take the place of Lifeline, Lifefone, or any other service which a person is now using. In fact, we urge people to continue to use those services in addition to the CARE program.

Any information provided to the Jacksonville Department of Public Safety as part of the process to subscribe to this service will be totally confidential, and only used by First Responders as needed.

If you have questions before signing up, please call our Community Services Division at Jacksonville Public Safety, 910-455 1472, any time Monday through Friday between 8:00am and 3:00pm. Feel free to leave a message with your name and number and someone in the Community Services Division will be in touch with you.

Consent: By checking the box below, I agree to participate in Jacksonville Public Safety's CARE program. I do hereby give permission to Emergency and Law Enforcement representatives to respond appropriately to any perceived emergency situation involving my health and or safety. An alternative key holder is identified on my interview form, and I give my permission for them to release the key for emergency First Responders. It is my understanding the information contained on the interview form will be released to Law Enforcement and Emergency Personnel as necessary for me to participate in the CARE Program.

I consent to participate in Jacksonville Public Safety's CARE Program

Today's Date: *

WAIVER: To release and hold harmless the City of Jacksonville and the Jacksonville Public Safety against any claim in relations to service(s) received through the CARE Program. Subscriber(s) acknowledge the City of Jacksonville and Jacksonville Public Safety Services (Police and Fire) are providing the service as a public service and for no compensation. Subscriber(s) recognizes the City of Jacksonville and Jacksonville Public Safety Services may, in their sole discretion, terminate this service at any time. Subscriber(s) also acknowledges technical problems or human error may result in a failure of the service at any time. In consideration of these factors, the Subscriber(s) hereby waives, releases, and holds harmless the City of Jacksonville and Jacksonville Public Safety Services (Police and Fire) from any claim(s) arising from a failure, for any reason, to provide the services contemplated by this agreement, and subscriber(s) further agrees to waive, release, and hold harmless the City of Jacksonville and Jacksonville Public Safety Services (Police and Fire) any claim for direct, incidental, or consequential damages arising from any act or omission of the City of Jacksonville and Jacksonville Public Safety Services (Police and Fire), their Volunteers, Agencies, or Employees, in connection with the City of Jacksonville and Jacksonville Public Safety Services (Police and Fire) participation in this program.

I consent to the waiver as outlined above.

Today's Date: *

The following section is intended to provide personal information to be used by Jacksonville Public Safety Police and Fire to best serve the subscriber as part of the CARE program. This information will be totally confidential, and only used as necessary by Jacksonville Police and Fire First Responders.

You are provided space for up to 4 emergency contacts. Not all spaces need to be filled.

Desired Call Time: *

AM or PM?

AM

PM

Subscriber's First Name: *

Subscriber's Last Name: *

Subscriber's Middle Initial:

Subscriber's Date of Birth: *

Subscriber's Street Address: *

Subscriber's City of Residence: *

Subscriber's State of Residence:*

Subscriber's Zip Code: *

Does Subscriber have an answering machine?

Yes

No

Does Subscriber have any pets?

Yes

No

Subscriber's Apartment Building Name: (If you do not live in an apartment, skip this question).

Subscriber's Apartment Number: (If you do not live in an apartment, skip this question).

Subscriber's Church Clergy Name: (If you are not affiliated with a church, skip this question).

Subscriber's Church Clergy Phone Number: (If you are not affiliated with a church, skip this question).

Subscriber's Vehicle Information-Make, Model, Color, License Plate Number (If you do not own a vehicle, skip this question).

Subscriber's Home Phone Number: (If you only have a cell phone, skip this question).

Subscriber's Cell Phone Number: (If you only have a home phone, skip this question).

Does the Subscriber live alone?

Yes

No

Subscriber's Doctor's Name:

Doctor's Phone Number:

Does the Subscriber have any physical impairments?

Yes

No

If you answered yes to physical impairments, please describe:
If you answered no to physical impairments, skip this question.

Location of medication in the home: (If you do not take any medications, skip this question).

Does the Subscriber need assistance walking?

Yes

No

In case of emergency, notify:

Contact 1 Last Name: *

Contact 1 First Name: *

Contact 1 Middle Initial:

Contact 1 Relationship to Subscriber: *

Contact 1 Street Address: *

Contact 1 City: *

Contact 1 State: *

Contact 1 Zip Code: *

Contact 1 Home Phone: (If cell only, skip this question)

Contact 1 Cell Phone: (if home phone only, skip this question)

Contact 1: Does this person have a key to the subscriber's home?

Yes

No

Contact 2 Last Name:

Contact 2 First Name:

Contact 2 Middle Initial:

Contact 2 Relationship to Subscriber:

Contact 2 Street Address:

Contact 2 City:

Contact 2 State:

Contact 2 Zip Code:

Contact 2 Home Phone: (if cell only, skip this question).

Contact 2 Cell Phone: (If home phone only, skip this question)

Contact 2: Does this person have a key to the subscriber's home?

Yes

No

Contact 3 Last Name:

Contact 3 First Name:

Contact 3 Middle Initial:

Contact 3 Relationship to Subscriber:

Contact 3 Street Address:

Contact 3 City:

Contact 3 State:

Contact 3 Zip Code:

Contact 3 Home Phone: (If cell only, skip this question)

Contact 3 Cell Phone: (If home phone only, skip this question)

Contact 3: Does this person have a key to the subscriber's home?

Yes

No

Contact 4 Last Name:

Contact 4 First Name:

Contact 4 Middle Initial:

Contact 4 Relationship to Subscriber:

Contact 4 Street Address:

Contact 4 City:

Contact 4 State:

Contact 4 Zip Code:

Contact 4 Home Phone (If cell only, skip this question)

Contact 4 Cell Phone (If home phone only, skip this question)

Contact 4: Does this person have a key to the subscriber's home?

Yes

No

* indicates required fields.

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