Otis Police Wellness Check Form
Name (First, Last) *
Your answer
Address (House number, Street address) *
Your answer
When would you like to be checked on? *
Would you like to be called or checked in on personally
Whom should we call if we cannot contact you at one of the times that you indicated that you wanted to be checked on? *
Please include their phone numbers
Your answer
Please remember that it is your responsibility to call us if you are going away and don't wish to be checked on for a period of time. *
Please check that you understand.
Required
Is there anything else that you would like the police department to know about you, ie. reason you are asking to be checked on. Please remember that you don't need to be elderly or disabled to be on this checklist. We also check on people in remote locations. *
Your answer
Do you wish to have your information/wellness check on file in the senior center? The seniors will be checking on people periodically as well. If you choose no, we will keep your info confidential within the police department.
Please list your home phone number, as well as any cell phone number you may have, below. *
Your answer
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