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Senior Citizen Care Program

In the event of extreme weather conditions; such as a heat wave (three (3) or more consecutive days of 90 degree weather) or a cold snap (three (3) or more consecutive days of below zero), do you want the Burlington Township Police Department to call your residence to check on you? If yes, please submit the form below.
Name:  
Address:  
Home Phone:  
E-mail:
Cell Phone:
Emergency Contact #1  
Day Phone:   Evening Phone:
Emergency Contact #2
Day Phone: Evening Phone:
List any medical conditions: (If more than one individual has condition, list name then condition)
Doctor's Name
Doctor's Tel#
Is there a DO NOT RESUSCITATE (DNR) order in effect?  
If Yes, for who and where is it kept?
 
By clicking on SUBMIT you are requesting SENIOR CITIZEN CARE.
 

 
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