Surfside Beach, TX · Brazoria County
EMS Community Health Check Enrollment Form
Surfside Beach residents complete this form to enroll in the EMS Community Health Check program and share health information and preferred visit times.
What this form is
This form collects names, an address, an emergency contact, pertinent medical history, medications, allergies, special medical needs, and preferred days and times for visits. It is for people enrolling in Surfside Beach’s EMS Community Health Check program. The form directs participants to return it to the EMS Station or email it to the listed EMS contact.
Who needs it
People who want to participate in the EMS Community Health Check program provide their contact, health, and preferred visit-time information on this form.
How to submit it
Return the form to the EMS Station or email it to [email protected], as directed on the form.
About notarization
This document is completed without a notary; it names no notarized attachment or sworn step, and the form does not request a signature or date.
How to submit this form
- 1
Download The Form
Download the EMS Community Health Check Enrollment Form.
- 2
Complete The Form
Provide the requested names, address, emergency contact, health information, and preferred visit days and times.
- 3
Gather Attachments
The form does not list any required attachments.
- 4
Submit To The City
Return the completed form to the EMS Station or email it to [email protected].
Frequently asked questions
- Do I need a notary for the EMS Community Health Check form?
- No. The form does not request a notary, signature, or date, and it identifies no notarized attachment or sworn step.
- How do I submit the EMS Community Health Check form?
- Return it to the EMS Station or email it to [email protected], as the form directs.
- What information does the form ask for?
- It asks for names, an address, an emergency contact and phone number, pertinent medical history, medications, allergies, special medical needs, and preferred visit days and times.