Emergency Information Sheet

Stay Safe Alert Emergency Information Sheet

Complete one form per device user. Fields marked * are required.

This form sends your information by email to Stay Safe Alert. It is not an emergency alert and does not immediately update your monitoring record. For an emergency, call 911.

1. Customer and service location

First name *

Last name *

Date of birth *

Primary phone *

Submitter email address *

Service address *

Apartment / Unit / Room

City *

State *

ZIP code *

Submission type *

2. Emergency contacts

Please provide at least two contacts when possible, in the order they should be contacted.

Contact 1

Name

Relationship

Primary phone

Alternate phone

Contact 2

Name

Relationship

Primary phone

Alternate phone

Contact 3

Name

Relationship

Primary phone

Alternate phone

Contact 4

Name

Relationship

Primary phone

Alternate phone

Contact 5

Name

Relationship

Primary phone

Alternate phone

3. Information important during an emergency

List only information important for emergency response. For conditions and allergies, write “None” if none apply.

Major or life-threatening medical conditions *

Severe allergies and known reactions *

Include mobility aids, hearing or speech needs, memory loss, oxygen in the home, pets, or other responder-safety information, if applicable.

Mobility, communication, or safety information

4. Emergency entry information

If the primary entrance is locked, how may emergency personnel enter? Select all that apply.

Garage code Lockbox Hidden key Key holder or emergency contact Building staff or front desk Door normally unlocked Other No alternate entry method available

Provide only information necessary for emergency access. This information may be shared with the monitoring center and emergency responders when needed.

Location, code, contact name, or other entry instructions

5. Customer confirmation

I confirm that the information provided is accurate to the best of my knowledge. I authorize Stay Safe Alert to share this information with its monitoring center and emergency responders when reasonably necessary for monitoring, dispatch, or emergency response. I understand that I am responsible for notifying Stay Safe Alert when this information changes. *

Signature or typed name *

Printed name *

Relationship to device user, if applicable

Date *

Supported payment methods

My cart

Stay Safe Alert Emergency Information Sheet

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