To register for the "You Are Not Alone" Program, please complete the form below and click the submit button. The information will be sent to the American Red Cross and they will contact the person who is to receive the calls (the Call Recipient). If you need more information about the program, please call the American Red Cross at 914-946-6500 ext. 450. Click here for more information.
(fields in red with an asterisk are required)
 
*Please indicate who you are enrolling: Self Relative/Friend
If you are enrolling someone other than yourself, please answer the following:
Your Name:
Your phone:
(Please include area code)
I have discussed this program with my relative/friend and she/he agrees to take part in the “You Are Not Alone” computerized calling program. Yes No

*Call Recipient's Phone Number
 (Please Include Area Code):

*Requested Time of Daily Call:

 AM PM
*Recipient's First Name:
*Recipient's Last Name:
Recipient's Middle Initial:
*Street Address:
Apt. Bldg Name:
Apt. Number:
*City:
*State:
*Zip/Postal Code:
*Primary Doctor's Name:
*Primary Doctor's Phone
 (Please Include Area Code):
Clergy's Name:
Clergy's Phone
 (Please Include Area Code):

         In Case of Emergency, Notify:
*#1 Emergency Contact First Name:
*#1 Emergency Contact Last Name:
*Street Address:
Apt. Bldg Name:
Apt. Number:
*City:
*State:
*Zip/Postal Code:
 *Phone
 (Please Include Area Code):
#2 Emergency Contact First Name:
#2 Emergency Contact Last Name:
Street Address:
Apt. Bldg Name:
Apt. Number:
City:
State:
Zip/Postal Code:
  Phone
 (Please Include Area Code):

                      Next of Kin:
 Next of Kin First Name:
 Next of Kin Last Name:
Street Address:
Apt. Number:
City:
State:
Zip/Postal Code:
  Phone
 (Please Include Area Code):
*Are Keys on Premises? Yes No
Keyholder's First Name:
Keyholder's Last Name:
Street Address:
Apt. Bldg Name:
Apt. Number:
City:
State:
Zip/Postal Code:
  Phone
(Please Include Area Code):
Does the Recipient have pets? Yes No
Type of Pet:
Pet Location:
*Does recipient live alone? Yes No
Co-Residents' Name:

   Is the Call Recipient also interested in any of the following:
Telephone Reassurance: Yes No
Nutrition Counseling/Special Dietary Needs: Yes No
Emergency Medical Information Bag: Yes No
Home visit/Case Mgt. Assessment: Yes No
Medicare Counseling: Yes No
Additional Comments:
(Maximum 1000 characters)