Pleasantville, MT · Atlantic County
Senior Lifeline Call-In Program Form
Pleasantville seniors use this form to join the Fire Department’s daily call-in program and provide contact and optional medical precaution information.
What this form is
This form collects information for Pleasantville’s Senior (Lifeline) Call-In Program, which checks on participating local senior citizens by phone each morning. It asks for the participant’s name, birth date, phone numbers, emergency contacts, and a key holder, and provides space for optional medical precaution information. It also includes authorization for emergency personnel to enter the participant’s home if needed.
Who needs it
Pleasantville senior citizens who want to participate in the Fire Department’s daily call-in program can provide their contact and emergency information on this form.
How to submit it
Send the completed form to the Pleasantville Fire Department at 1 North First Street, Pleasantville, New Jersey 08232, or email [email protected].
About notarization
This form is signed without a notary; it lists no notarized or sworn attachments, so the signer just signs and dates it.
How to submit this form
- 1
Download The Form
Download the Senior Lifeline Call-In Program form.
- 2
Complete The Form
Fill in the senior’s contact information, emergency contacts, and key holder details; provide medical precaution information if desired.
- 3
Gather Attachments
The document does not list any required attachments.
- 4
Submit To The Fire Department
Send the completed form to the Pleasantville Fire Department by mail or email using the contact details shown on the form.
Frequently asked questions
- Who can use the Pleasantville Senior Lifeline Call-In Program form?
- The form is for local senior citizens who want the Pleasantville Fire Department to call them daily and check on their well-being.
- What information does the form ask for?
- It asks for the senior’s name, birth date, phone and cell numbers, address, emergency contacts, and a key holder. It also offers space for optional medical precaution information.
- Do I need a notary for the Pleasantville Senior Lifeline Call-In Program form?
- No. This form is signed without a notary, and it lists no notarized or sworn attachments; the signer just signs and dates it.
- How do I submit the Pleasantville Senior Lifeline Call-In Program form?
- Send it to the Pleasantville Fire Department at 1 North First Street, Pleasantville, New Jersey 08232, or email [email protected].