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R.U.O.K Sign Up
 
Broward Sheriff's Office
City of Weston
"Are You O.K.?" Interview Form
 
 Subscriber
Date: 5/16/2012
First Name MI Last Name
Street Address Apartment #
()  - 
Phone Number Answer Machine?
 
Emergency Contact Information
First Name MI Last Name
Street Address Apartment #
City State Zip
()  - 
Phone Number Answer Machine?
 
  Yes / No    
Key on premises?  /  Key location:
Pets?  /  Type:
Live alone?  /  Co-residents:
Able to walk?  /  Impairments:
 
Time to call: :00
 
Days to call:
  Check all that apply.
 
This program is not intended to take the place of a physician. If you are
experiencing a medical emergency, contact 911 immediately.


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