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  1. Senior Information Sheet
  2. Subscriber Information
  3. Castle Rock
  4. Colorado
  5. Hearing impaired?
  6. In Case Of An Emergency, Notify
  7. Next of Kin Information (not residing with you)
  8. Same as emergency contact
  9. Key Location/Occupant Information
  10. Extra Key
  11. Pets
  12. Life Alert
  13. House Alarm
  14. Are there weapons in the home?
  15. Live Alone
  16. Vehicle
  17. Medical History
  18. Able to walk
  19. Physical Impairments:
  20. By submitting my application, I agree to having a Castle Rock Police Officer or Volunteer contact me with further information and to discuss my potential enrollment into the R-U-OK program.*
  21. Leave This Blank:

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