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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.