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2. Fill out the form carefully for registration.
4. 
6. APPLICANT INFORMATION
8. First Name
9. Middle Name
10. Last Name
12. Address
14. City
15. State
16. Zip Code
18. Date of Birth
20. Primary Phone Number

    1. Home
    2. Cell
21. Phone Number
23. Secondary Phone Number

    1. Home
    2. Cell
24. Phone Number
26. Email Address
30. EMERGENCY CONTACTS
32. Emergency Contact
34. Key Holder?

    1. Yes
    2. No
36. Phone Number
38. Secondary Phone Number
40. Email Address
44. Second Emergency Contact
46. Key Holder?

    1. Yes
    2. No
48. Phone Number
50. Secondary Number
52. Email Address
56. 3rd. Emergency Contact
58. Key Holder?

    1. Yes
    2. No
60. Phone Number
62. Secondary Number
64. Email Address
68. Medical Conditions?
70. Driving?

    1. Yes
    2. No
71. Driving License Number
73. Home Security Alarm?

    1. Yes
    2. No
75. Vehicle(s):
77. Do you hide a key?

    1. Yes
    2. No
79. Where should the deputy look for they key?
81. Any other information a deputy should know upon arrival? Aggressive pet? Unlocked window? Etc.
85. Release of Liability
87. First Name
88. Last Name

90. The named above covenants and agrees to release from liability and hold harmless the County of Randolph, the Sheriff of Randolph County, and their respective representatives, employees, agents, volunteers and officials from any loss, damage or harm arising out of their acts, omissions or conduct of whatever nature as it pertains to participation by said Sheriff, his representatives, employees, agents, volunteers and officials in the Citizens Well-Check Program.

     

    This the ___________ day of _________________. 20_____

92. ELECTRONIC SIGNATURE OPTION*

    1. I ACCEPT
    2. I DO NOT ACCEPT

    By clicking I ACCEPT using any device, means of action, I acknowledge that all the information on this application is true and accurate to the best of my knowledge.  I also understand that any misrepresentation or falsification of information will result in my denial or removal from the program.

96. For Sheriff's Office Information

    Zone ________    Picture Provided __________     Add to weather notification __________

Leave This Blank:


98. 1. Receive an email copy of this form.
99. Email address

    This field is not part of the form submission.

100. Submit

* indicates a required field