RUOK APPLICATION

Camden County 911 RUOK Program Application and Waiver

Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Primary Phone*

Secondary Phone

Email Address

Best time to call you*

Contact Information in case of Emergency

Emergency Contact Name

First Name

Last Name

Emergency Contact Home Phone

Emergency Contact Cell Phone

Key available at home location?*

YES NO

If YES, list the location

Is there anyone else we can contact who has a key? Enter Name and phone number or No one.*

Pets at the location?*

YES NO

If YES, what type of animal

Do you live alone?*

YES NO

If NO, Enter Name and phone number. If YES, enter No one.

Are you able to walk?*

YES NO

List any physical or medical impairments.

Are you taking any medications?*

YES NO

If YES, list medications.

Any remarks or questions you have for us?

If at any time you wish to be removed from or suspend the RUOK Program, Please call (912)729-1442.
Thank You for allowing us to serve you.

CAMDEN COUNTY SHERIFF’S OFFICE 209 E 4TH ST., WOODBINE, GA 31569 KINGSLAND POLICE DEPARTMENT 111 S. SEABOARD ST., KINGSLAND, GA 31548 ST MARYS POLICE DEPARTMENT 563 POINT PETER RD., ST MARYS, GA 31558 “WAIVER” RELEASE AND HOLD HARMLESS THE CAMDEN COUNTY SHERIFF’S OFFICE, KINGSLAND POLICE DEPARTMENT, AND ST. MARYS POLICE DEPARTMENT AGAINST ANY CLAIM IN RELATION TO SERVICE RECEIVED THROUGH THE R.U. OK PROGRAM. Subscriber acknowledges that the Camden County Sheriff’s Office, Kingsland Police Department and St. Mary’s Police Department are providing this service as a service and for no compensation. Subscriber recognizes that the Camden County Sheriff’s Office, Kingsland Police Department and St. Mary’s Police Department may, in their sole discretion, terminate this service at any time. In consideration of these factors, subscriber hereby waives, releases and hold harmless the Camden County Sheriff’s Office, Kingsland Police Department, and St. Mary’s Police Department from any claim arising from a failure, for any reason, to provide the services contemplated by this agreement, and subscriber further agrees to waive, release and hold harmless the Camden County Sheriff’s Office, Kingsland Police Department, and St. Mary’s Police Department against any claim for direct, incidental, or consequential damages arising from any action or omission of the Camden County Sheriff’s Office, Kingsland Police Department, and St. Mary’s Police Department, government of Camden County, City of Kingsland, and the City of St. Mary’s their volunteers and/or employees, in connections with the Camden County Sheriff’s Office, Kingsland Police Department, and St. Mary’s Police Department participating in this program.

Name*

First Name

Last Name

Date/Time

:

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