Date of Birth: * Address: * City/State/Zip Code * Home Phone #: Cell Phone #: Other Phone #: Race: * Preferred Language: * English Spanish Emergency Contact's Name: * Emergency Contact's Relationship to Senior: * Emergency Contact's Address: * Emergency Contact's City/State/Zip Code: * Emergency Contact's Home Phone #: Emergency Contact's Cell Phone #: Do you have pets? If so, how many and what type? Do you live alone? List other occupants here. Do you have Life Alert? Do you have an alarm system? If yes, what company? Vehicle(s)? Please state their make/model/year/color: Do you have any physical impairments? List all: Are you able to walk? Please check the times you are available to be called for a wellness check: *
Choose multiple time slots, based on your availability.
Please select all of the days you are available to be contacted for a wellness check: *
Choose multiple days, based on your availability.
If there is any additional information that is important for deputies to know, please type it in the space below: By choosing yes below, I voluntarily give permission to the Harris County Precinct 6 Constable's Office to use my personal information above to communicate with me regarding health, safety, and future senior events, as well as to enter my residence for the purpose of checking the well-being of myself and my family. I understand that by selecting yes, my information is solely for Harris County Precinct 6 Constable's Office and will NOT be shared. Please select yes if you agree: * Yes No
You may opt out of the RUOK Program and communications from Precinct 6 Constable's Office at any time by contacting Miriam Muguerza at 713-274-3424
Today's Date: *