Senior Information Form

The purpose of this form is to identify homebound seniors within Floyd County in need of assistance. If you are in such a situation, please provide your information below to show your desire to be added to the database. Depending on the selected services, information will be shared with EMS and potentially the Sheriff's office, if the requested option is through the Sheriff's office. Basic information will be retained by the Floyd County Administration, HIPPA data will be retained by EMS.

First name

Last name

Physical Address

Number of people in the home

Are there pets in the home? If so, describe.

Phone

Cell Phone for text messages

Emergency Contact-Email and/or Phone Number

Are you currently acknowledged by the power company as having a medical assistance device(s) in the event of a power outage?

If you responded yes, which device(s) do you use?

What are some of the services you may require right now?

Other Comments

Would you like a follow-up call to discuss specific health concerns?