NEWFIELDS POLICE & FIRE DEPARTMENT

“HELPFUL HANDS”

MEMBERSHIP FORM

NAME: ____________________________________________ DOB: __________________________

MAILING ADDRESS: ________________________________________________________________

PHYSICAL ADDRESS: _______________________________________________________________

TELEPHONE: __________________________ CELL PHONE: _____________________________

FIRST EMERGENCY CONTACT SECOND EMERGENCY CONTACT

NAME: ________________________________ NAME: ________________________________

PHONE: _______________________________ PHONE: _______________________________

RELATIONSHIP: _______________________ RELATIONSHIP: _______________________


DOES ANYONE HAVE A KEY TO YOUR HOME? (Circle) YES NO

NAME: _______________________________________ PHONE: _____________________________

DO YOU HAVE ANY SPECIAL CONSIDERATIONS? (Circle) YES NO

SPECIAL CONSIDERATIONS: (circle which apply) Deaf or Hard of Hearing

Blind or Low Vision Wheelchair user Confined to Bed Limited Movement Other

PLEASE EXPLAIN ANY SPECIAL CONSIDERATIONS:


DO YOU NEED SPECIAL MEDICATIONS OR HAVE ALLERGIES TO MEDICATIONS?

PLEASE EXPLAIN:


DO YOU DRIVE? (Circle) YES NO

DESCRIPTION OF VEHICLE: __________________________ PLATE #: ___________________


DOCTOR’S NAME: _________________________________ PHONE: _______________________

APPLICANT SIGNATURE: ____________________________________ DATE: _______________

PROCESSED BY: _____________________________________________ DATE: _______________