LOCKBOX APPLICATION

LOCKBOX APPLICATION

PHARR FIRE DEPARTMENT
The Residential Lockbox Program is intended to expedite access to older adults in their own homes during medical or other emergencies, while eliminating the likelihood of property damage from forced entry.
Applicant Information

The person residing in the home where the lock box will be attached.
Applicant Name*

First NameLast Name
Home Phone*
Cell/Other Phone
Date of Birth

MonthDayYear
Date
Drivers License or ID Number
Physical Address*

Street Address

Apt. / Suite / Room

CityState / Province

Postal / Zip Code

Emergency Contact #1 Information

A person we can call if we cannot reach the applicant.
Emergency Contact Name*

First NameLast Name
Home Phone*
Cell/Other Phone
Date

MonthDayYear
Date
Relationship
Name of Workplace
Workplace Phone
Address

Street Address

Apt. / Suite / Room

CityState / Province

Postal / Zip Code

Emergency Contact #2 Information

A person we can call if we cannot reach the applicant.
Emergency Contact Name

First NameLast Name
Home Phone
Cell/Other Phone
Date

MonthDayYear
Date
Relationship
Name of Workplace
Workplace Phone
Address

Street Address

Apt. / Suite / Room

CityState / Province

Postal / Zip Code

Provide information regarding medical conditions, pets, alarms, or other information the fire department should maintain on file.
Please check the reason for the application:*

I am 65 years of age or older and living alone or I am alone on a frequent basis.I have a medical condition that is potentially incapacitating and I live alone or I am alone on a frequent bases

Please initial the following statements:
initials* I acknowledge that I will contact the Pharr Fire Department if I move or wish to withdraw from the Lockbox Program . I understand that the lock box is the property of the Pharr Fire Department.
initials* By participating in the Lockbox Program, I authorize the Pharr Fire Department to enter my residence for emergency purposes only and to install the lock box onto my property.
initials* In consideration for my participation in and benefiting from this Program, the receipt and sufficiency of such consideration are hereby affirmed: I agree to indemnify and hold harmless the City of Pharr, its elected and appointed officials, officers, employees and representatives from any and all actual or alleged claim, demand, lawsuit, liability, loss, damage, injury, or death, including all reasonable costs of defense, arising out of or in any way relating to my participation in this Program.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Primary Care Physician Information