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2. Lincolnton Police Department RUOK? Program

   Sign up for RUOK (Are you ok?), a program designed to provide a means of checking on the elderly, sick, home-bound, or disabled persons that live alone or that do not have family that can check on them on a consistent basis. This program is available to subscribers on a volunteer basis to those citizens that want the service.

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6. First Name*
7. Last Name*
9. Address1*
11. City*
12. State*
13. Zip*
15. PRIMARY Phone Number*
16. Secondary Phone Number
18. Email Address*
19. Please answer the following questions: (Check all that apply)*

    1. Lives Alone
    2. Able to walk

    1. Key on premises
    2. Has pets
21. Emergency Contact Name*

    First Name / Last Name

22. Emergency Contact Phone Number*
24. Please BREFLY explain your need for the RUOK program.
26. Signature (Type Name)*

    By signing this request, you acknowledge that the Lincolnton Police Department has permission to contact you by phone, email, or in person as part of the R U OK program. 

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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field