Reassurance Intake Form

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Emergency Contacts (must have at least 2)

  • Authorization and Release

  • The goal of the CONTACT Altoona Reassurance Program is to promote the general welfare and safety of its clients. The success of this goal sometimes depends on the ability to enter the homes of people who may be in need of immediate medical aid.
    In the event of an emergency, I hereby request CONTACT Altoona to notify the back-up people, designated by me, to enter my residence. Should those people be unavailable, I agree that CONTACT shall notify and request the police to enter my residence by force if necessary to aid me in what appears to be an emergency situation.
    I release and forever discharge CONTACT Altoona, and/or its agents, from all claims, damages, actions, causes of action, or suits at law or in equity, of whatsoever kind or nature, for or because of any matter or thing suffered to be done by the said CONTACT Altoona after and including the date hereof, on account of all injuries to property resulting from such breaking and entering.
    I have also been advised that CONTACT Altoona will do their best to make the calls daily. They have also advised me that they might not be able to have someone call every day and that it is possible that more than 24 hours can pass between telephone calls.
    It is understood that this authorization and release from liability is binding upon me, my heirs and/or assignees, and the terms of this release are understood by me.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.