Alzheimer's Association, New York City Chapter
360 Lexington Ave., 4th Floor, New York, NY 10017
Telephone: 800.272.3900

The New York City Chapter wants to ensure that everyone who needs the protection of the MedicAlert + Safe Return Program is enrolled, regardless of their ability to pay.

If the person with dementia cannot afford to pay for enrollment, a Scholarship is available and will be paid for by the Alzheimer's Association, NYC Chapter Special Assistance Fund.

Only individuals with Alzheimer’s or related dementia are eligible for the MedicAlert + Safe Return program

Registrant information

Member Last Name ________________________________

First Name _______________________________________

Nickname ________________________________________

Street address ____________________________________

City ____________________________________________

County __________________________________________

State ____________   Zip code ______________________

Telephone _______________________________________

Social Security No. _________________________________

Date of birth ______________________________________

Male___   Female ___

Height _________________   Weight __________________

Eye color  ______________   Hair color ________________

Race/ethnicity ____________________________________

Skin tone : Fair___   Medium___   Dark___

Language ________________________________________

Health Insurer  _____________________________________

Details Check all that apply and add description/location

Mole  _________________________________________ 

Tattoo  ________________________________________ 

Scar  _________________________________________   

Birthmark  _____________________________________

Law Police Phone (not 911)  ________________________
(police or sheriff department nearest registrant’s residence)

Circle the characteristics that apply:

Medical conditions
(Check the box next to each of your conditions and write in any others. While these conditions are very important, any condition that requires continued physician care or special attention in an emergency should be noted.)

Other ____________________________________________

Drug Allergies

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

Medications List all medications and dosages, including inhalers

Member ID jewelry Check type and style       

Exact Wrist Measurement: __________inches
(Required for bracelet)

Bracelet measurement instructions: Use a flexible tape measure to determine wrist size, or encircle wrist with string and measure string against a ruler.

Caregiver Information

Primary contact/caregiver is called first if a person is found and may arrange to return registrant.
IDs are sent to this address, unless otherwise specified

Full Name ______________________________________

Mailing Address __________________________________

City ____________________________________________

County __________________________________________

State ____________   Zip code ______________________

Home phone _____________________________________

Cell phone _______________________________________

Work phone ______________________________________

Relation to member_________________________________

Additional contacts can be called and receive information if a person is missing or found.

Full Name _______________________________________

Address _________________________________________

City ____________________________________________

County __________________________________________

State ____________   Zip code ______________________

Home phone _____________________________________

Cell phone _______________________________________

Work phone ______________________________________

Relation to member_________________________________

Full Name _______________________________________

Address _________________________________________

City ____________________________________________

County __________________________________________

State ____________   Zip code ______________________

Home phone _____________________________________

Cell phone _______________________________________

Work phone ______________________________________

Relation to member_________________________________

OPTIONAL Caregiver ID Jewelry and membership Check type and style

Exact Wrist Measurement: __________inches
(Required for bracelet)

Bracelet measurement instructions: Use a flexible tape measure to determine wrist size, or encircle wrist with string and measure string against a ruler.

CONSENT
Important: By accepting membership in MedicAlert Foundation, for yourself as member or caregiver and/or as caregiver on behalf of the member named above (collectively, “you”), you authorize MedicAlert to release all medical and other confidential information about you in emergencies and to other health care personnel you designate. If you choose to terminate membership, you must notify us in writing and return your jewelry. MedicAlert relies upon the accuracy of the information that you provide. You, therefore, agree to defend, indemnify, and hold MedicAlert (including its employees, officers, directors, agents, and organizations with which it maintains a marketing alliance for the provision of services hereunder) harmless from any claim or lawsuit brought by member or others for injury, death, loss or damages arising in whole or in part out of your provision of incomplete or inaccurate information to MedicAlert. Furthermore, as caregiver for the member named above, you hereby represent and warrant to MedicAlert that you have full power and authority

Furthermore, I hereby represent and warrant to the Alzheimer’s Association that I have full power and authority as the duly authorized representative of the registrant named above, to register and act on his or her behalf.

Contact signature __________________________________
(Signature/Consent required for registration.)

Date ____________________________________________

Initial enrollment fee $49.95
Optional caregiver membership and jewelry ($25.00)
Shipping and Handling $4.95

Total: ___________

Payment method:

___NYC Chapter Scholarship (please contact NYC Chapter MedicAlert + Safe Return Staff at 1.800.272.3900

___Phone registration   ___ Mail registration

___Check $_______

___Visa  

___MasterCard

___America Express

Credit card number _________________________________

Exp. date ________________________________________

Cardholder’s name _________________________________

Cardholder’s signature ______________________________

Mail form, photo, and payment to:

MedicAlert^® + Safe Return^®
New York City Chapter
360 Lexington Avenue, 4th Floor

New York, NY 10017

Phone
To enroll by phone, call toll-free
1-800-272-3900 (24 hours a day, every day)

To update any enrollment information,
please call 1.888.572.8566.