C.H.I.P SERVICE REQUEST FORM

CHIP PARTICIPANT

First Name

Last Name

BIRTHDATE

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

REQUESTED BY

RELATIONSHIP

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PREFERRED METHOD OF CONTACT

TELEPHONE CALL

PERSONAL VISIT

DAY

TIME

FREQUENCY

EMERGENCY CONTACT

First Name

Last Name

RELATIONSHIP

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

CLOSEST NEIGHBOR

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

NAME OF GENERAL PHYSICIAN

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

WHAT IS YOUR CURRENT HEALTH SITUATION?

ANY SERIOUS HEALTH PROBLEMS?

ARE YOU ALLERGIC TO ANY DRUGS?

DO YOU HAVE AND PETS?

IF YES, PLEASE FILL OUT THE CHAPARRAL PINES PET REGISTRATION FORM.

COMMENTS

PARTICIPANT'S SIGNATURE

Date

YYYY

SIGNATURE OF PERSON MAKING REQUEST

Date

YYYY

Participation in the CHIP Program does not establish a special relationship between the CHIP participant and the Chaparral Pines Community Association. A duty to call you on the phone, respond to your home, or summon emergency aid if you fail to answer your telephone is not established. The CHIP agencies and their volunteers will not be liable to you or any person claiming through you, for any act or omission which proximately causes injury or property damage to you or others as a result of your home not being called, or for failure to respond to your home if you do not answer a call.

C.H.I.P SERVICE REQUEST FORM

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