FREESTONE COUNTY SHERIFF'S DEPARTMENT     
                       SheriffCare APPLICATION              
 

Applicants Name                        Address
________________________     _____________________ 

Phone Number                          City
________________________     _____________________                     

Doctor’s Name and Location     Minister’s Name and Phone

_________________________   _________________________

_________________________   _________________________

_________________________   _________________________                        

Emergency Contact                           Emergency Contact

Name________________________      Name__________________

Address______________________      Address ________________

City_________________________       City ___________________

Phone _______________________       Phone _________________

Emergency Contact                            Key Holder

Name________________________       Name__________________

Address______________________       Address_________________

City_________________________        City____________________

Phone________________________       Phone__________________

               
                           Physical Impairments or Handicaps

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

List any medications you are taking, any allergic reactions to medication,
or any other information you feel we should know.

____________________________________________________________
____________________________________________________________

____________________________________________________________

Are there any animals on the property?  (  ) Yes  (  ) No    

What Kind? __________________________________________________

____________________________________________________________

Do you live alone? (  ) Yes   (  ) No     Co-residents _________________

Are you able to walk (  ) Yes  (  ) No

List physical impairments _______________________________________

Is there an outside key to the residence?  (  ) Yes  (  ) No

If there is an outside key, where is it located? ______________________

_____________________________________________________________

What time(s) do you wish to be called? _____________________________________________________________