Please complete the online subscription form below or download the PDF form PDF form Title Name Preferred Language Preferred Language French English Date of Birth (DD/MM/YYYY) Address: Apt #: Ring #: City: Province: Postal Code: Intersection: Tel #: Other #: Landline telephone provider: Email: Home alarm system? Home alarm system? Yes No Do you have a lockbox? Do you have a lockbox? Yes No Lockbox code: Do you live alone? Do you live alone? Yes No Do you require a Subsidy? Do you require a Subsidy? Yes No Notice of Assessment required Notice of Assessment required Copy provided Do you identify as an Indigineous Person? Do you identify as an Indigineous Person? Yes No No Selection Name Tel #: Relation: Notes: Allergies: Location of medication: Medical information for responders Special requirements Referral information: Referral information: Bruyère Client Other hospital Advertisements Support worker Medical office Family & friends Social media ODSP / POSPH Veterans affairs Other Other 1. Name: 1. Relation: 1. Home #: 1. Cell #: 1. Work #: 1. Email: 1. Alert preference 1. Alert preference Email Text / SMS Portal access 2. Name: 2. Relation: 2. Home #: 2. Cell #: 2. Work #: 2. Email: 2. Alert preference 2. Alert preference Email Text / SMS Portal access 3. Name: 3. Relation: 3. Cell #: 3. Home #: 3. Work #: 3. Email: 3. Alert preference 3. Alert preference Email Text / SMS Portal access Building superintendent #: Building emergency service #: I wish to receive periodic information from Red Dot Alerts I wish to receive periodic information from Red Dot Alerts Yes No Terms of Service Terms of Service I agree to the Terms of Service and to provide a completed pre-authorized payment from prior to the start of the service. Client or guarantor name: Signature Date submit If you have additional information to supplement what is provided on this form, please submit separately with your recent Notice of Assessment to firstname.lastname@example.org .