2. 
3. 
4. 
6. You Are Not Alone Program (Y.A.N.A.) Request
   Do you or someone you know live alone? Would you like a safety visit from the Woodland Police Department? Did you know the Woodland Police Department volunteers provide welfare checks to Woodland residents who primarily live alone or are bedridden through our You Are Not Alone (Y.A.N.A) Program? Many times their only contact may be through the personal visits of our volunteers, therefore enhancing the quality of lives of our residents. Please note we do not provide medical assistance, but rather a measure of security with our visits. Participants must provide authorization by submitting an application form for us to begin our visits. You Are Not Alone (Y.A.N.A.) is designed for the purpose of visiting individuals who do not get out or very seldom leave their homes. Upon their request, they are visited by our volunteers on a regular basis. The fulfillment of this program is contingent on the availability of volunteer personnel.
8. Advance Notice Required*

   I understand that a one week notice is requested for a You Are Not Alone visit request.

   1. I understand.
10. Participant Information
12. First Name*
13. Last Name*
15. Physical Address*
17. City*
18. State*
19. Zip Code*
21. Home Phone Number*
22. Cell Phone Number
24. Email Address
28. Alternate / Emergency Contact Information
30. First Name*
31. Last Name*
33. Address*
35. City*
36. State*
37. Zip Code*
39. Best Contact Number*
40. Best time to be reached:
    Best time to be reached: Start Time

    —

    Best time to be reached: End Time
42. Email Address
46. Residential Property Information
48. Animal(s) on premise?*

    1. Yes
    2. No
49. Type of Animal(s)?
50. Location on premise?
    Example: backyard, inside, etc.
52. Alarm on premise?*

    1. Yes
    2. No
53. Alarm Company Name
54. Alarm Company Phone Number
56. Is there backyard access?*

    1. Yes
    2. No
57. Is there side yard access?*

    1. Yes
    2. No
58. Names of Authorized Persons to be on premise:*
    Example: Relative, Neighbor, Friend, Gardener, etc.
60. General Heath Information
    Please list any general health information you would like to share with us.
62. Request Verification*

    I AGREE THAT ALL ABOVE INFORMATION IS ACCURATE. I ALSO AGREE TO ALLOW WOODLAND POLICE DEPARTMENT PERSONNEL TO CONDUCT A Y.A.N.A. CHECK AT MY RESIDENCE.

    1. I agree.
64. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
66. Electronic Signature
67. Today's Date
    Today's Date
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field