To register for the "You Are Not Alone" Program, please complete the form below and click the submit button. The information will be sent to the Weed Police Department and they will contact the person who is to receive the calls (the Call Recipient). If you need more information about the program, please call the Weed Police Department @ 530-938-5000. 

*Please indicate who you are enrolling: Self Relative/Friend If you are enrolling someone other than yourself, please answer the following: Your Name:     Your phone: (Please include area code) I have discussed this program with my relative/friend and she/he agrees to take part in the “You Are Not Alone” calling program. Yes No *Call Recipient's Phone Number (Please Include Area Code): *Requested Time of Daily Call: AM PM *Recipient's First Name: *Recipient's Last Name: Recipient's Middle Initial: *Street Address: Apt. Bldg Name: Apt. Number: *City: *State: *Zip/Postal Code: *Primary Doctor's Name: *Primary Doctor's Phone (Please Include Area Code): Clergy's Name: Clergy's Phone (Please Include Area Code):          In Case of Emergency, Notify: *#1 Emergency Contact First Name: *#1 Emergency Contact Last Name: *Street Address: Apt. Bldg Name: Apt. Number: *City: *State: *Zip/Postal Code:  *Phone (Please Include Area Code): #2 Emergency Contact First Name: #2 Emergency Contact Last Name: Street Address: Apt. Bldg Name: Apt. Number: City: State: Zip/Postal Code:   Phone (Please Include Area Code):                       Next of Kin:  Next of Kin First Name:  Next of Kin Last Name: Street Address: Apt. Number: City: State: Zip/Postal Code:   Phone (Please Include Area Code): *Are Keys on Premises? Yes No Keyholder's First Name: Keyholder's Last Name: Street Address: Apt. Bldg Name: Apt. Number: City: State: Zip/Postal Code:   Phone (Please Include Area Code): Does the Recipient have pets? Yes No Type of Pet: Pet Location: *Does recipient live alone? Yes No Co-Residents' Name:    Is the Call Recipient also interested in any of the following: Telephone Reassurance: Yes No Nutrition Counseling/Special Dietary Needs: Yes No Emergency Medical Information Bag: Yes No Home visit/Case Mgt. Assessment: Yes No Medicare Counseling: Yes No Additional Comments: (Maximum 1000 characters)