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Account Information:

Please provide us with some information about the person who will be receiving Friendly Jingle calls. Once submitted, you will receive an email and/or a phone call from our care-coordinator.

*First Name:

*Last Name:

*Your Friendly Jingle Plan:

*Add-On Option - Weekend Calls $10/Month:

Requested Start Date and Preferred Time of Day for Calls:

*Primary Phone Number:

*Street Address:

*City:

*State:

*ZIP Code:

*Please provide the phone number of the client's local paramedic, in case of an emergency (not 911):

*Please provide the phone number of the local police department, in case of an emergency (not 911):

List any special needs and specific requests for our Friendly Jingle Care-Callers: (example: “Please remind her to take her medication.” Or “We just want someone to check in to make sure he’s ok.” Or “I need to be reminded to change my bandage.” )

List any hobbies or interests that you’d like your Friendly Jingle Care-Caller to ask about: (example: “She enjoys quilting, reading and watching game shows.” “He likes talking about sports and current evens.”)

*Please provide your phone number or a family member or friend that we may contact if we are unable to reach your loved one

*Please provide your email address:

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