Safety and Well-Being Monitoring Registration Form

Please provide the following contact information (to be completed by the Parent/Guardian/Elder Caregiver initiating the service):

 

First Name		First Name
Last Name		Last Name
Street Address		Street Address
Address (cont.)		Address (cont.)
City		City
State/Province		State/Province
Zip/Postal Code		Zip/Postal Code
Country		Country
Home Phone		Home Phone
Work Phone		Work Phone
E-mail		E-mail

 

Please provide the following Client information (to be completed on behalf of the Child(ren) or Elder(s) service is being initiated for):

 

Client #1 (Primary Contact Person for 247 Care’s Counselor)

 

First Name
Last Name
Nickname
Date of Birth
Health Card Number
Primary Care Physician
Street Address
Address (cont.)
City
Emergency Phone

Management Data:

 

Allergies:  Medications/Foods to be avoided…  and Why?  Please explain.

 

Procedures to be avoided…  and Why?  Please explain.

 

 

Client #2 (Sibling or partner/spouse of Client #1)

 

First Name
Last Name
Nickname
Date of Birth
Health Card Number
Primary Care Physician
Street Address
Address (cont.)
City
Emergency Phone

 

Management Data:

 

Allergies:  Medications/Foods to be avoided…  and Why?  Please explain.

 

Procedures to be avoided…  and Why?  Please explain.

 

 

Please use the space provided to give details of any additional children and/or elders to be monitored at your residence.

 

Emergency Contact Information (i.e. please identify one neighbor in close proximity to your residence)

 

First Name
Last Name
Relationship
Home Phone
Work Phone
E-mail
First Name
Last Name
Relationship
Home Phone
Work Phone
E-mail

 

 

Please help us serve you better by completing our Needs Assessment:

 

Check the days you/your family will be requiring Monitoring:
Monday  Tuesday  Wednesday  Thursday  Friday  Saturday  Sunday

 

Check what applies to your/your family’s Monitoring requirements:

Full Year                                     

Summer only

Temporary or Emergency Monitoring

Rotating Schedule Monitoring

24-Hour Monitoring

Open Holidays

 

What daytime hours and/or what nighttime hours will you/your family be requiring Monitoring?  Please specify exactly what time you/your family would like to have a 247 Care counselor check-in. 

 

Language(s) spoken in home:

 

Special Needs

Do you/your family have any special needs?  Check One    yes      no

If yes, please provide details.

 

Do you/your family have a pet that will need to be monitored?

Check One  yes    no

 

How long do you/your family anticipate needing 247 CARE’ s Safety and Well-being Monitoring service?

 

How did you/your family find out about 247 CARE?

 

Please list any other concerns or questions you/your family may have:

 

Please contact me as soon as possible regarding this matter.

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