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2. The "Blue Angel " program will look to encourage residents to download online applications to address personal needs regarding their household members related to developmental disabilities, seniors who suffer from dementia or Alzheimer's disease, or seniors who live alone and may require frequent welfare checks (spare key locations).
3. Once the completed application is received the information will be recorded with the Department's 911 dispatch center in an effort to tailor our response capabilities to the residence or individual. The information provided will aid in officers tailoring their interactions between persons with a disability or by expediting the rendering of aid on welfare checks thus reducing unneeded property damage by forcing entry.
7. Applicant's Contact Information
9. First Name*
10. Middle Name
11. Last Name*
13. Home Address*
15. City*
16. State*
17. Zip Code*
19. Home Phone Number*
20. Cell Phone Number
21. Email Address*
23. Date of Birth*
    Date of Birth
24. Photo Upload*
    Please attach a photograph of the person who is the subject of this application:
26. Reason for Application*

    1. am 55 years of age or older and live alone or am alone on a frequent basis.
    2. I have a medical condition that is potentially incapacitating and live alone or I am alone on a frequent basis.
    3. am a person with a developmental disability or mental illness.
    4. I am a person who suffers from Dementia, Alzheimer's or similar condition.
28. Describe the reason for your application:*
30. Doctor's Name*
31. Doctor's Phone Number*
35. Emergency Contact #1
37. Full Name*
38. Email Address
40. Home Address*
42. City*
43. State*
44. Zip Code*
46. Home Phone Number*
47. Cell Phone Number*
49. Emergency Contact #2
51. Full Name*
52. Email Address
54. Home Address*
56. City*
57. State*
58. Zip Code*
60. Home Phone Number*
61. Cell Phone Number*
65. Do you have a living will or Do Not Resuscitate (DNR) Form?*
    -- Select One --YesNoUnknown
67. If yes, where is it located?
71. Liability Release
    In consideration of my participation in Operation Blue Angel, the undersigned, to the fullest extent permitted by law, hereby agrees on behalf of the undersigned the undersigned and the undersigned’s heirs and representatives, to release, indemnify and hold harmless the Township of East Brunswick and their respective employees, officers, and agents from and against any and all claims, suits, judgments, losses, damages, personal injuries (including but not limited to death), or liability (including reasonable attorney's fees), directly or indirectly arising from or in connection with the undersigned’s participation in Operation Blue Angel. The undersigned acknowledges and agrees that the undersigned’s participation in Operation Blue Angel is voluntary and that said program is being offered only as a courtesy. I also understand and agree that Operation Blue Angel is not intended to nor does it in any way whatsoever create or impose a special duty on the East Brunswick Police Department or East Brunswick Township and their respective employees, officers, and agents regarding the undersigned’s safety or well- being of person or property.
73. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
75. Program Participant Electronic Signature*
76. Legal Guardian Electronic Signature
80. Community Policing Unit
    For additional questions regarding this Blue Angel Application, please contact the Community Policing Office by emailing CommunityPolicing@ebpd.net or calling 732-390-6938.
Leave This Blank:


82. 1. Receive an email copy of this form.
83. Email address

    This field is not part of the form submission.

84. Submit

* indicates a required field