Check-In Calls Signup

Please take a few minutes and fill out this form so that we can get started on setting up your Monitored Check-In Calls account! Please provide as much information as possible. We will review your document after its submitted and contact you if we have any questions.

Please note: Aside from the information regarding the person that will be checking in, you will need the following information to complete this form:
- Names and Phone numbers of the people we will call if we do not receive a check-in and are unable to reach the client.
- Times for the calls and any relevant notes regarding the calls.

Once you submit this form, your completed information will be sent to us and a copy will be sent to you as well. Should you have any questions, please feel free to contact us and we will be glad to help you through this process.

First, we will collect information regarding the person that will be checking in.

Name of person:

Complete Address of person to be called (Street, City, State, Zip):

Date of Birth:

Primary Phone Number

Secondary Phone (If Needed)

Additional Number (If Needed)

Please select the numbers that you will be calling from to check in:

Are there any issues that we should be aware of if we have to contact you?

Next we will gather detail on who you would like us to reach in the event that we cannot reach you if a check-in is missed.

How many people do you want us to try to reach if we cannot contact you?

Name of First Person to Reach:

First Number To Try:

Type of Phone:

Second Number To Try

Type of Phone:

Name of Second Person to Reach:

First Number To Try:

Type of Phone:

Second Number To Try

Type of Phone:

Name of Third Person to Reach:

First Number To Try:

Type of Phone:

Second Number To Try

Type of Phone:

In the event that neither the Subscriber nor their contacts answer our calls, the Subscriber does hereby authorize Towne Monitoring Service 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 Service.

OK - now we'll gather information about when you would like to check in and any other information you think we would need.

When filling in the time, please write times as 1110A or 700P as this will help avoid any confusion. Thank you!

Your check-in window will start at 4:00am. Please tell us what time you would like to check in by - in other words, what time of the day should we attempt to reach you if our system hasn't heard from you.

Latest Check-In Time:

Are there any special notes or instructions?

Please enter the name and email address of the person completing this form:

Your Name:

Your Email Address

That's it , you've finished!

Below you will see our Care Calls agreement. This form, along with the answers that you've given above, will be sent to the email address that you provided above as record of completion. Upon review from our programmers, we will contact you with any questions we may have and to arrange payment.

Thank you for choosing Towne - We look forward to serving you.