Senior Roll Call Form

NCCPD Lifeline Logo

 

Senior Roll Call Lifeline Enrollment Application

Your Preferred Phone - Home/Cell/Work?
Your 2nd Phone - Home/Cell/Work?
Clear
Desired Call Time - (Select One)
Select Days to be Called - Select All Desired
Do you attend any Senior Centers?
Days You Attend (Select All That Apply)

Please list in order of preference, the names of those you would like us to contact if we are unable to reach you during your call time. Please discuss this program with your emergency contacts and let them know we may call them if we cannot reach you. Ask what their preferred method of contact is, Home, Cell, or Work. Please choose people who are familiar with what you do and where you go each day, if possible.

**** To add additional contacts, click on the green button and scroll down. 

Is Contact Preferred Phone - Home/Cell/Work?
Is Contact 2nd Phone - Home/Cell/Work?
Clear
Is Contact a Key Holder?

Please answer the questions below:

Are you able to walk?
Do you live alone?
Do you have any pets?
Do you keep a key hidden outside your home?
Do you drive?

Use the area to provide any special instructions or notes:

Release and Waiver

I,   release and forever discharge New Castle County Government (the “County”), its heirs, executors, administrators, agents and assigns, from any and all claims, demands, actions, causes of action or suits of any kind or nature whatsoever as it relates to my participation in the Senior Roll Call Lifeline Program.

Either place your cursor in the 'Signer's Name' box to type your name or use your mouse to draw your name next to the 'X'.
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