Reassurance CONTACT application form

If you wish to receive a daily Reassurance CONTACT call, please fill out the following information and hit SUBMIT. The person receiving the call must be in the city limits and citizen of Weaverville, NC.

Name

Email (optional)

Telephone

Time to Call

Street Address

List two people we may call if we are unable to reach you.

Contact Name 1

Does contact 1 have a key to your home?

Yes
No

Contact 1 Phone

Contact Name 2

Contact 2 Phone

Does contact 2 have a key to your home?

Yes
No

Emergency Numbers

Primary Physician

Physician Number

Preferred Hospital

Telephone

Is there anyone else you would like us to call in case of an emergency? If yes, please list below.

Emergency Contact 1

Emergency Contact 1 Phone

Emergency Contact 1 Relationship to you

Emergency Contact 2

Emergency Contact 2 Phone

Emergency Contact 2 Relationship to you

Please list any special needs (medical conditions, handicaps, etc.)

Date of Birth

I wish to receive a daily reassurance call. I agree to notify the Weaverville Police if I will be unable to answer the telephone at our regular time. I give the Weaverville Police permission to have someone check on me in the event I do not answer the phone.

This is not a contract for security services and does not promise or create a warranty for any particular degree of police protection. The WPD security check program is a courtesy service only and does not create a "special relationship" with the proprty owner for purposes of the Police Duty Doctrine. The property owner and occupants acknowledge that the Weaverville Police Department cannot prevent all crimes from occuring.

Please type the text at the right.