First Name * Last Name * Date of Birth * Street Address * City * Phone Number (Primary) * Phone Number (Secondary) * Email * Medical Condition * Are you able to drive? * Hide a key? * Do you have pets? * Do you have a home alarm? * Primary Contact First Name: * Primary Contact Last Name * Primary Contact Address: * Primary Contact City: * Primary Contact Phone Number: * Does this person have a key? * Release of Liability * By entering your name above, you promise and agree to release from liability and hold harmless the Town of Angier, the Chief of Police, and their respective representatives. This includes all employees, agents, volunteers and officials from any loss, damage or harm arising out of their acts, omissions or conduct of whatever nature as it pertains to participation by the Chief of Police, his representatives, employees, agents, volunteers and officials in the Citizen Well-Check Program. Leave this field blank
