Project Lifesaver Application

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SOS Health Care, Inc. 843.449.0554 phone 843.497.4861 fax Monique Clement 843-602-8840 cell

Horry County Project Lifesaver Application

Date___________ Client Full Name____________________________________________________________ Client Address______________________________________________________________ Care Givers Name(s)_________________________________________________________ phone#__________________cell#____________________email_____________________ Client Information:

Birthdate:_________________________Race:__________________Sex:_______________ Height_________Weight_________Eye Color_________Glasses or Contacts Y/N_ ______ Hair Color_________Hair Style__________Bald Y/N_________Hearing Aid Y/N_______ Is your member a runner? y/n, if yes explain______________________________________ Have you ever had to call the police? If yes, explain________________________________ Facial Hair: mustache, beard, sideburns etc.______________________________________ Scars, marks and or tattoos:___________________________________________________ Primary Language Spoken_________Secondary Language Y/N______________________ Verbal or Non-Verbal______________ Sign Language Y/N Does client use any other form of communicating Y/N_____________

Does client drive or have access to a vehicle? (If yes, describe vehicle and plate number): ___________________________________________________________________________ Medical Diagnosis: (you will need to provide a copy of your diagnosis) __________________________________________________________________________ Medication:_________________________________________________________________ ___________________________________________________________________________ Medical History:_____________________________________________________________ ___________________________________________________________________________ Attending Physician Name & Number:___________________________________________ Please describe the best way to approach client if he/she is lost________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ If any, name a few key words or phrases to get clients attention (if they have a favorite food, song, friends name etc)__________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Comments or Questions:_________________________________________________________ _____________________________________________________________________________ Horry County Public Safety Sponsor

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