FREESTONE COUNTY SHERIFF’S OFFICE
P. O. DRAWER 47
FAIRFIELD, TX. 75840

Freestone County Sheriff’s Office "SheriffCare"  
Program Consent Form
 

I, ________________________, agree to participate in the Freestone County Sheriff’s Office’s SheriffCare program.  I do hereby give my permission to Emergency and Law Enforcement representatives to respond appropriately to any perceived emergency situation involving my health and/or safety.

A key holder(s) is also identified on my interview form and I give my permission for him/her to release the key for emergency response.

It is my understanding that the information contained on the interview form will be released to Law Enforcement and Emergency Personnel as necessary for me to participate in the SheriffCare program.

In the event I will be away from home during a scheduled SheriffCare call time, I agree to advise the Freestone County Sheriff’s Department at (903) 389-3236 prior to the SheriffCare call.  This will help to avoid a false alert.

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Signature                                            Date             

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Interviewer                                        Date