Are You Ok? Form

 

 

 

Please complete and submit the RUOK form below.  You will then be contacted by someone from the Constable Precinct 3 office.

Date


Subscriber Information

First Name*

Last Name*

Date of Birth*

Street Address*

City*

State*

Zip Code*

Home Phone ###-###-####*

Age*

Are you living alone?*

Occupants*


In Case of Emergency, Notify

First Name

Last Name

Relationship

Street Address

City

State

Zip Code

Home Phone

Work Phone

Cell / Alt Phone


Next of Kin Information

First Name

Last Name

Relationship

Street Address

City

State

Zip Code

Home Phone

Work Phone

Cell / Alt Phone


Key Location / Occupant Information

Extra Key

Extra Key Location

Pets

Description

Life Alert

Description

Alarm?

Company

Vehicle?


Make

Model

Year

Color



Medical History

Able to walk?

Description

Physical Impairments

Description


Miscellaneous Information/Remarks

Gender

Ethnicity

Marital Status


Race (Check all that apply)


I, the undersigned, freely and voluntarily give permission to the Harris County Pct. 3 Constable's Office to enter my residence for the purpose of checking on the well-being of myself or my family. To sign the form, please type in your full name in the Signature field below:

Signature*

Date*

 
Spelling...Spelling...

SubscriberFName *

DateFormFilledOut

SubscriberLName

SubscriberDOB *

SubscriberAge *

SubscriberLiveAlone *

SubscriberOccupants

SubscriberStreetAddress *

SubscriberCity *

SubscriberState *

SubscriberZip *

SubscriberHomePhone *

EmergencyNotifyFName

EmergencyNotifyLName

EmergencyNotifyRelationShip

EmergencyNotifyStreetAddress

EmergencyNotifyCity

EmergencyNotifyState

EmergencyNotifyZip

EmergencyNotifyHomePhone

EmergencyNotifyWorkPhone

EmergencyNotifyCellAltPhone

NextOfKinFName

NextofKinLName

NextOfKinRelationship

NextOfKinStreetAddress

NextOfKinCity

NextOfKinState

NextOfKinZip

NextOfKinHomePhone

NextOfKinWorkPhone

NextOfKinCellAltPhone

ExtraKey

ExtraKeyLocation

Pets

PetsDescription

LifeAlert

LifeAlertDescription

Alarm

AlarmCompany

Vehicle

VehicleMake

VehichleModel

VehichleYear

VehichleColor

AbleToWalk

AbleToWalkDescription

PhsycalImpairments

PhsycalImpairmentsList

MiscInfoGender

MiscInfoEthnicity

MiscMaritialStatus

MiscInfoRace

Signature *

signdate *

Attachments

 
AreYouOk