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Senior Outreach Program

  1. Groveland Public Safety- Senior Outreach Program
  2. APPLICATION/EMERGENCY INFORMATION
    EACH Participant Must have a completed Emergency Information form.
  3. NOTIFY IN CASE OF EMERGENCY NEXT OF KIN
  4. LOCAL FRIEND/NEIGHBOR
  5. KEY HOLDER INFORMATION
  6. DOES ABOVE LOCAL FRIEND/NEIGHBOR HAVE A KEY TO YOUR HOME, IF NEEDED:
  7. (If above noted friend does NOT have a key, please supply name of someone who will have a key.)
  8. Vehicle Information
  9. I understand that as a participant in GPSCO Senior Outreach that our conversations may be recorded and subject to public disclosure upon request.
  10. Preferred Day of Call
  11. Agreement
    By clicking "I Agree," you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your "electronic signature" is valid and binding upon you to the same force and effect as a handwritten signature.
  12. Leave This Blank:

  13. This field is not part of the form submission.