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2. Senior Information Sheet
4. Subscriber Information
6. Name*
7. Date of Birth*
9. Address1*
11. Castle Rock
12. Colorado
13. Zip
15. Phone Number (xxx-xxx-xxxx)*
16. Alternate Phone Number
17. Email Address*
19. Hearing impaired?

    1. Yes
23. In Case Of An Emergency, Notify
25. Emergency Contact #1 Name*
26. Relationship:
28. Address:
30. City
31. State
32. Zip
34. Home Phone*
35. Alternate Phone
36. Email Address*
38. Emergency Contact #2 Name
39. Relationship
41. Address
43. City
44. State
45. Zip
47. Home Phone
48. Alternate Phone
49. Email Address
53. Next of Kin Information (not residing with you)
55. Same as emergency contact

    1. Yes
57. Contact 1
58. Relationship
60. Address
62. City
63. State
64. Zip
66. Home Phone
67. Alternate Phone
68. Email Address
70. Contact 2
71. Relationship
73. Address
75. City
76. State
77. Zip
79. Home Phone
80. Alternate Phone
81. Email Address
85. Key Location/Occupant Information
87. Extra Key

    1. Yes
    2. No
88. Key Location:
90. Pets

    1. Yes
    2. No
91. Pet Description:
93. Life Alert

    1. Yes
    2. No
94. Company Name:
95. Company Phone Number:
97. House Alarm

    1. Yes
    2. No
98. Alarm Code:
100. Are there weapons in the home?

     1. Yes
     2. No
101. If yes, location of weapons:
103. Live Alone

     1. Yes
     2. No
104. Other Occupants:
106. Vehicle

     1. Yes
     2. No
107. License Plate #
108. Make/Model:
109. Year/Color:
111. Garage Code:
112. Gate Code:
116. Medical History
118. Able to walk

     1. Yes
     2. No
119. If needing assistance, describe:
121. Physical Impairments:

     1. Yes
     2. No
122. If yes, describe:
124. Additional notes to better assist CRPD when attempting contact with you.
126. If you are submitting this form for the applicant, include your first and last name here.
128. 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.*

     1. I Agree
Leave This Blank:


129. 1. Receive an email copy of this form.
130. Email address

     This field is not part of the form submission.

131. Submit

* indicates a required field