New Telecare Application Client Name(Required) First Last Address(Required) Street Address Address Line 2 City INAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence(Required)County of ResidenceBlackfordDelawareFayetteHenryJayRandolphUnionWayneOtherOther County(Required) Home Phone(Required)Cell PhoneEmail Demographic DataThe following data is not used for eligibility for the Telecare Program.Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required) Female Male Other Ethnicity: African American Asian Caucasian American Indian Hispanic Other Contact InformationTelecare calls are made between the hours of 8:00 a.m. and 5:00 p.m. Monday through Sunday. Please indicate the times you would like to be called. You may have up to three calls per day.I want my Telecare calls to begin on this date:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please indicate what day(s) of the week you would like to be called.(Required) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Call Times(Required)Up to three calls are available from 8AM-5PM, Monday through Sunday. 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM Other Information:Please check all that apply.Please call for:(Required) Social Call Safety Check Medication Reminder Please:(Required) Do NOT call back if I am not reached. Do NOT call the police if I am not reached. Call back every 15 minutes if I am not reached. Call contacts if I am not reached after 1 hour. Client NotesIn the space below, please write any issues that need checked on:Medical HistoryPlease indicate any family history or medical issues in the space below:HobbiesIn the space below, please write any interests or hobbies you have:Preferred Contact InformationEmergency Contacts (list up to three contacts)(Required)First NameLast NameRelationshipHome #Cell #Work # Add RemoveClick the (+) button to add additional contacts.How did you hear about Telecare? LifeStream A Better Way Website Church Hospital Community Presentation Other Would you be interested in additional services through LifeStream?NoYesEmailThis field is for validation purposes and should be left unchanged.