Aging & Disability

Emergency Contact Form

Suppose you live alone. What would happen if you became ill or were injured at home and lost consciousness? Do you have a support network of people who check in on you? How long would it take for neighbors or Society Members to notice you’re not around? We’d like to help you develop an emergency protocol whereby you provide basic contact information that we can keep in our USR office.

Please print out the Emergency Contact Form below and return it with names, phone numbers and even e-mails of local and non-local people we would contact for you in the event you can’t do it yourself. This information will be kept securely in the office and only used in an emergency situation.

USR Emergency Contact Form