LifeLine Application

LifeLine Requirements

Name*
First Last
Phone*
Is this number a Land Line or a Cell Phone?*
- Land Line
- Cell Phone
Email
Address*
Home Location, no PO Box numbers Cross Street City State Zip
Birth Date*
Month
Day
Year
Medical Conditions*
Name of your local Ambulance/EMT service.*
Do you have a key hidden in the outside of your home that an EMT could use to enter the home in case you are not able to unlock the door?*
Primary Care Physician*
Name of your preferred hospital*
We need the name and contact info of three contact people you trust.
Contact 1: Full name*
Contact 1: Telephone*
Contact 1: Do they have keys to enter your home?*
- Yes
- No
Contact 2: Full name*
Contact 2: Telephone*
Contact 2: Do they have keys to enter your home?*
- Yes
- No
Contact 3: Full name*
Contact 3: Telephone*
Contact 3: Do they have keys to enter your home?*
- Yes
- No
After you press the 'Submit' button, the NFWFWF Grant Coordinator will receive your information and send it to our representative at LifeLine. An appointment will be arranged to set up your new service at a time that is convenient for both of you. Please leave us a message if you have any questions at 631-477-8464. We will be back to you.