Onboarding Application #140

Name

Email

Phone

Preferred Notification Method

Address

City

Zip Code

State

Time Zone

Broadband Provider Name

Broadband Provider Account

Residence Type

Size of residence

Sq Ft

Local Police Phone Number

Local Fire Phone Number

Local Sheriff Phone Number

How many people live with subscriber?

Birth year of subscriber?

Does anyone make regular visits to the subscriber?

Does someone live within 15-minute driving distance of subscriber?

Is the subscriber capable of answering the phone?

Does the subscriber use an assistive device to walk?

Is the subscriber wheelchair bound?

Is the subscriber bed bound?

Does the subscriber have a history of falls?

Is the subscriber capable of reading and following simple instructions?

Is the subscriber capable of taking medication as directed?

Is the subscriber capable of leaving their home on their own?

Desired Installation Date

Preferred hours?