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TeleCare Application

Telecare Application

To print & mail your application fill in this form and then press the printer key in the toolbar. Mail completed form to: 450 East Romie Lane Salinas, CA 93901 Attn: Volunteer Services and Service League OR Complete form below and submit online.

* Required Field

*Last Name:

*First Name:

Address:

City:

Zip:

*Home Phone:

* Email:

Business Phone:

*Cell/Pager:

*Date of Birth (MM/DD/YYYY):

Doctor:

Doctor's Phone Number:

1st Alternate:

Name:

Address:

Phone:

2nd Alternate:

Name:

Address:

Phone:

1. Provide Telecare with names, addresses and telephone numbers of two alternatives. An Alternate is someone we can call if you do not answer your telephone. This person should be a neighbor, close friend or family member who lives nearby, who has a key to your home and your permission to to check your premises in case you do not answer your Telecare telephone call. This protection is for your protection in case you are unable to answer your telephone abd need help. There is no charge for the daily Telecare service. Please Note: If 911 is called on your behalf, you will be responsible for all charge that may result from the emergency call.

2. Have you discussed this with your Alternate (person we are to call if we cannot get you) and obtained permission to present their name for this responsibility?
Yes No

3. Does your Alternate have a key to your home, in case of emergency?
Yes No

4. What time do you prefer to be called? (Make a second choice)

8:45 - 9:15 a.m. 9:15 - 9:45 a.m. 9:45 - 10:45 a.m. 10:15 - 10:45 a.m.

5. Check the days you wish to be called

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

6. Please remember to inform us when you are not going to be home in order to avoid calling your alternate unecessarily. (This applies to vacations, away for the day, doctor visits, etc.)

7. Are you handicapped in any way?

8.Do you have Medic-Alert Identification?

9. Do you drive an automobile? Yes No

License#

10. Who told you about Telecare?

11. The Service League has my permission to share this information with the local police in the event there is concern for my personal welfare.