Sebastian Police

First Name

Sebastian, FL 32958

Street Address

Sebastian Police Department
1201 Main Street
Sebastian, FL 32958
Background Investigator: Officer Steve Marcinik
Tel (772) 589- 5233 X8576	Fax (772) 388-4410	Email:smarcinik@cityofsebastian.org

RUOK Sebastian Site#

Sebastian Police Department is happy to introduce our new program called RUOK. This program is designed to help care for our Special Needs, Homebound, Disabled and Senior Citizen population. All you have to do is fill in the form below and we have our computer generated software program call you at your residence with the question: RUOK? This program is available 24hrs a day, 7 days a week. Please fill in all appropriate blocks below:


Phone Number

Date of Birth
	Impairments or Illnesses


Emergency Contact Name	Phone Number	Relationship

Check the answer that best suits the question:
Able to walk?	Yes No	Wheelchair or Walker Yes No
Lives alone?	Yes No	If No, please complete co-resident information
Have Pets?	Yes No	If yes, in House or Yard


Co-Residents Names

Location of Medication	Location of Medical records

Doctor's Name	Doctor's Phone Number

Church or Clergy Name	Clergy's Phone Number

Check Days(s) of week to Call	Mon Tues Wed Thurs Fri Sat Sun
Time of Day to Call ?	AM PM
Applicant Signature
Date


Received	Entered	Dispatch
(Include Initials, ID#, Date & Time)


Inhouse (Form B-3)RUOK(Revised 9/2006)

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