Zone: __________ Provided picture: ____ Add to weather emergency notifications: _______
Randolph County Sheriff’s Office
Citizens Well-Check Program
Name:______________________________________ DOB:_________________
Address:________________________________________________________________
City:__________________________________ Zip Code:___________________
Home Phone #:________________________ Cell Phone #: _____________________
Door most used at the home: ______________________________________________
1
st
Emergency Contact: _________________________________ Key holder? Yes No
Home Phone #: ___________________ Cell Phone #: ___________________
2
nd
Emergency Contact: ________________________________ Key holder? Yes No
Home Phone #: ___________________ Cell Phone #: ___________________
3
rd
Emergency Contact: ________________________________ Key holder? Yes No
Home Phone #: ___________________ Cell Phone #: ___________________
Medical Condition(s):_______________________________________________________
Driving: Y/N DL#: _____________ Home Security Alarm: Y/N
Vehicle(s):_______________________________________________________________
Hide-a-way Key:___________________________________________________________
Release of Liability
____________________________covenants and agrees to release from liability and hold
harmless the County of Randolph, the Sheriff of Randolph County, and their respective
representatives, employees, agents, volunteers and officials from any loss, damage or harm
arising out of their acts, omissions or conduct of whatever nature as it pertains to participation
by said Sheriff, his representatives, employees, agents, volunteers and officials in the Citizens
Well-Check Program.
This the __________ day of ________________________, 20___
Signature of Participant ____________________________________________________
