Sign Up for Your 24-Hour Personal Emergency Response System Name Thank you for choosing Towne Monitoring Service as your Personal Emergency Response System provider! We look forward to working with you to set up your account . If you have any questions along the way - please don't hesitate to contact us. Please take a few minutes and fill out this form so that we can get started on programming your account. Be sure to provide as much information as possible. We will review your document after its submitted and contact you if we have any questions. Once we review your information and have all of the details that we need, we will contact you to make payment and delivery arrangements. Thank you! Specific Information you will need to complete this form: 1) The information regarding the party to be monitored. Requirements can be seen on this page by scrolling. 2) Names and phone numbers of desired contacts on the account. You will need at least two. 3) Think about what you would like us to do in the event that we cannot communicate once we connect to the system. Your Name (the person filling out this form) * Your email address * Which PERS unit is desired? Please Choose The Appropriate Configuration Libris Mobile Cellular PERS, $99.00 with $31.95 monthly monitoring MXD At-Home Landline, Pendant Version, $99.00 with $24.95 monthly monitoring MXD At-Home Landline, Wrist Version, $99.00 with $24.95 monthly monitoring CTS At-Home Landline, Alert Watch Version, $129.00 with $24.95 monthly monitoring CTS At-Home Landline, Talking Pendant Version, $129.00 with $24.95 monthly monitoring MXD3G At-Home Cellular, Pendant Version, $199.00 with $34.95 monthly monitoring MXD3G At-Home Cellular, Wrist Version, $199.00 with $34.95 monthly monitoring Numera Flex PERS, Basic Kit, $149.00 with $34.95 monthly monitoring Name of Person to be have PERS unit: * Street Address * City * State * Zip * Township / Borough / Municipality * Nearest Cross Street * Phone Number * Type of phone * Home Phone Cell Phone Date of Birth * Is there a Do Not Resuscitate (DNR) in place? Yes No Are there any illnesses or allergies that we should share with Emergency Services? Is there anything that the operator should be aware of when responding? Please provide any Spare Key Location or Access Information to be provided to Emergency Services Okay - now that we have gathered information regarding who we will be monitoring, we'll head to the next page for emergency contact information. Below we will gather information for the contacts that you would like to have on your account. How many people are to be on the contact list? * 2 3 4 Name of First Person To Reach: * Relationship to client: * Has Keys Yes No First Number To Try: * Type of Phone * Cell Home Work Second Number To Try: Type of Phone Cell Home Work Name of Second Person To Reach: * Relationship to client: * Has Keys Yes No First Number To Try: * Type of Phone * Cell Home Work Second Number To Try: Type of Phone Cell Home Work Is there anything that we should be aware of when attempting to call one of these contacts? Okay - now that we have your contact information, we'll move on to some protocol choices. Please use the Next Page button below to advance or the Previous Page button to go back to the first page. Please read the following carefully - Your system includes two-way voice and is meant to be heard under optimal conditions throughout most of the house. In the event that the two-way audio is not clear, or the operator does not hear audio, subscriber authorizes Towne to follow emergency response procedures. Towne will notify emergency services first, unless otherwise told in writing. Subscriber authorizes Towne in its sole discretion to authorize forcible entry, or to give access information if available, to gain access to Subscriber's premises in the event the System emits a signal to the Central Station and the Subscriber cannot be heard through the unit's microphone nor does the subscriber answer the telephone. Subscriber does hereby release the operator and Towne from any and all liability whatsoever as a result of said forcible entry. In the event the Subscriber utilizes the System to give the Central Station a signal, the Subscriber does hereby authorize Towne to seek to notify and/or obtain assistance. The Subscriber shall be obligated for and agrees to pay any costs and expenses incurred including, but not limited to, ambulance, physician or other medical assistance in obtaining assistance, or any cost whatsoever incurred as a result of the Subscriber's use of the System. In the event that I / we are not able to communicate with Towne's operator, please notify.... the Ambulance first. my contact(s) first, Okay - we've completed all of our information gathering for your account! Please click Next Page below to see your completed Monitoring Services agreement. You will be able to submit your information once you have reviewed your agreement. Below is our Monitoring Agreement. By scrolling to the bottom of the form and hitting the Submit Button, you are acknowledging that you have read the agreement. You will get a copy of all of the information that you have submitted and a copy of this agreement automatically mailed to you upon submission. As with anything else - if you have any questions, please feel free to contact us.