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WELFARE CHECK PROGRAM

   


This program is provided by the
Tarrant County Constable's Office Pct. 7 to insure the safety of those citizens who may ocassionally need a helping hand. Individuals who may me be ill, injured, post surgery, elderly, or without family in the area may qualify for this program. Upon receiving your submitted form, our Office will let you know if you qualify for this service.

How the program works

This program works by a representative of this office contacting you on a specific day and time to insure that you are okay. Our office will make three attempts by phone. After the third attempt and no contact is made, one of our Deputies will go by your residence in an attempt to make contact with you. It is the responsibility of the undersigned subscriber / participant to contact our office if for some reason he / she leaves the location during the requested contact time.

Waiver - Release and hold harmless agreement with the Tarrant County Constable's Office Precinct 7 against any claim in relation to service received through the Welfare Check Program.

The undersigned subscriber / participant acknowledges that the Tarrant County Constable's Office Precinct 7, is providing the Welfare Check Program as a public service and for no compensation. The subscriber / participant acknowledges that the Tarrant County Constable's Office Precinct 7, may, in its sole discretion, terminate this service at any time. The subscriber / participant also acknowledges that technical problems or human error may result in a failure of the service at any time. On consideration of these factors, the subscriber / participant hereby waives, releases, and holds harmless the Tarrant County Constable's Office Precinct 7, from any claim arising from a failure, for any reason, to provide the services contemplated by this agreement, and subscriber / participant further agrees to waive, release, and hold harmless the Tarrant County Constable's Office Precinct 7 against any claim for direct, incidental, or consequential damages arising from any action or omission of the Tarrant County Constable's Office Precinct 7, and its employees, in connection with the Tarrant County Constable's Office Precinct 7's participation in this program including any damage to the physical premises of the subscriber / participant occasioned by the necessary forced entry of the premises to carry out the stated goals of the program.

REQUESTERS INFORMATION

First Name: *
Last Name: *
Address Street: *
City: *
Zip Code: * (5 digits)
State:
Daytime Phone: *
Evening Phone:
Email: *
                       SERVICE NEEDED FOR
Name: *
Address: *
City: *
Zip Code: *
Phone: *
 Please choose a time frame for our system to call and check on the subscribers welfare


Days that you want us to call you (please check all that apply)
Sunday Monday Tuesday Wednesday

Thursday Friday Saturday

Is this a temporary request? Yes No

If Yes, what is the date you will end service?

 

Emergency Contact Number 1

Last Name First Name
Street Address
Apartment Number if Applicable
City State ZIP Code
Home Number Work Phone Other #

 

Emergency Contact Number 2

Last Name First Name
Street Address
Apartment Number if Applicable
City State ZIP Code
Home Number Work Phone Other #

 

Clergy Information (Optional)

Name
Name of Church
Phone Number Work Phone Other #

 

Doctor Information (Optional)

Name
Hospital
Phone Number Work Phone Other #

 

Next of Kin Information 1

Last Name First Name
Street Address
Apartment Number if Applicable
City State ZIP Code
Home Number Work Phone Other #

 

Next of Kin 2

Last Name First Name
Street Address
Apartment Number if Applicable
City State ZIP Code
Home Number Work Phone Other #

 

Is there a key on the premises? Yes No
Does one of the above listed persons have a key? Yes No
if yes, who?

if no, is there a neighbor close who has a key and if so, who?


Are there pets at the location? Yes No
If yes for pets, type and location

Do you live alone? Yes No
if no, Co-Resident


Are you able to walk? Yes No

.
List any physical impairments

 Comments: