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Laurens County Sheriff's Office

216 W Main Street Laurens, SC 29360

Don Reynolds, Sheriff

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For more information on our community services,
call (864) 681-4509

Application for Senior Outreach Services

Participant Full Legal Name

Birthday

Home Phone

Cell Phone

Address

Years lived here:

Do you own a vehicle?

Vehicle Description:

Preferred Method of Contact:

Telephone Call

Personal Visits

Time of Day:

Morning

Afternoon

Emergency Contact Person: First and Last Name

Emergency Contact Person: Address

Emergency Contact Person: Phone

Emergency Contact Person: Relation to Applicant

Name of Closest Neighbor or Friend:

Friend/Neighbor Address:

Neighbor/Friend Phone:

Serious Health Issues:

Current Medications:

Participants Signature

Name of Person Making Request:

Phone Number:

Thanks for submitting! Someone will be in contact with you soon!

© 2017 Laurens County Sheriff's Office