Poland Township Government, 3339 Dobbins Road, Poland, OH 44514
Phone: 330.757.0733
Poland Township Government
3339 Dobbins Road, Poland, OH 44514
Phone: 330.757.0733

Senior Watch Programs

Senior-Watch-1

Poland Township Senior Watch Programs

The Poland Township Trustees have sponsored the “Poland Township Senior Watch Programs” mainly for the benefit of township’s senior citizens, but others may benefit as well. Shut-ins, wheelchair bound or SSL recipients are some additional examples.

The Poland Township Senior Watch Program application form is available below for download. The completed application can be fax to 330.757.1152 or mail to:
 
Poland Township Senior Watch Programs
3339 Dobbins Road
Poland, OH 44514
 
In addition, you can complete the online version of the form, available at the bottom of this page.
 
Download:

Online Form:
Progress Bar:

Page 1 of 6

Please complete the pertinent information for the senior citizen or individual needing Senior Watch services:

Name(*)
Please type your full name.

Address 1(*)
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Address 2
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City(*)
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State(*)
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Zip Code(*)
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Phone(*)
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Cell or Other Phone
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Date of Birth(*)
/ / Invalid Input

Age(*)
Invalid Input

SSN
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Application Requested by:

Requested By(*)
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Relationship(*)
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Your Email(*)
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Your Address 1(*)
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Your Address 2
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Your City(*)
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Your State(*)
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Your Zip Code(*)
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Your Phone or Cell(*)
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Physician Family/General information:

Physician Name(*)
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Physician Phone(*)
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General Health or Illness(*)
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Allergic to medications(*)
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1st Emergency Contact (Family Neighbors/Friends):

Relationship — (1st Contact)(*)
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Address — (1st Contact)(*)
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Address 2 — (1st Contact)
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City — (1st Contact)(*)
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State — (1st Contact)(*)
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Zip Code — (1st Contact)(*)
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Phone or Cell — (1st Contact)(*)
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2nd Emergency Contact (Family Neighbors/Friends):

Relationship — (2nd Contact)
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Address 1 — (2nd Contact)
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Address 2 — (2nd Contact)
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City — (2nd Contact)
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State — (2nd Contact)
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Zip Code — (2nd Contact)
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Phone or Cell — (2nd Contact)
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Last page—Submit Form!

Additional Information (Outside key/lockbox/etc.):

Additional Information
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