LW Resident Contact Information Update

Please provide us with your current contact information. Recently, volunteers made wellness calls to residents to see if they were alright and to see if they needed anything. We found many of the phone numbers we have on file did not work. We will update our Telephone Directory with your current numbers.

We also would like to update your emergency contact information and for our snowbirds, out of town dates and phone numbers as well as who has a key to your LW house (house watcher).

New questions will apprear based on answers you give.

THANK YOU
Date

Month Day Year
Date Hour Minutes AM/PM Option
Name of RESIDENT 1 *

First Name Last Name
Address in Lauderdale West *

Street Address ONLY

Street Address Line 2
Status - Resident 1 *

Owner Renter
Landline - Resident 1

Country Code Area Code Phone Number
Cell Phone - Resident 1

Country Code Area Code Phone Number
The number I prefer to have listed in the LW Telephone Directory (Resident 1) is:

My landline My cell phone Don't show my number in the LW Telephone Directory
Email address - Resident 1
May we update the emergency contact information for Resident 1?

Yes No
Emergency Contact Name for Resident 1?

First Name Last Name
Emergency Contact's Phone Number for Resident 1

Country Code Area Code Phone Number
Emergency Contact's Email address - Resident 1
example@example.com
Is Resident 1 a seasonal resident (snowbird)?

Yes No
I'm usually out of town from about (Resident 1)

Month Day Year
I usually return to Lauderdale West around (Resident 1)

Month Day Year
Name of a local person with an emergency key (Resident 1)?

First Name Last Name
Key holder's phone number (Resident 1)

Country Code Area Code Phone Number
Key holder's address (Resident 1)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name - RESIDENT 2

First Name Last Name
Status - Resident 2

Owner Renter
Landline - Resident 2

Area Code Phone Number
Cell Phone - Resident 2

Area Code Phone Number
The number I prefer to have listed in the LW Telephone Directory (Resident 2) is:

My landline My cell phone Don't show my number in the LW Telephone Directory
Email address - Resident 2
example@example.com
May we update the emergency contact information for Resident 2?

Yes No
Emergency Contact Name for person 2?

First Name Last Name
Emergency Contact's Phone Number for person 2?

Area Code Phone Number
Emergency Contact's Email address - person 2
example@example.com
Is Resident 2 a seasonal resident (snowbird)?

Yes No
Are the out of town and return dates the same as Resident #1?

Yes No
I'm usually out of town from about (Resident 2)

Month Day Year
I usually return to Lauderdale West around (Resident 2)

Month Day Year
Name of a local person with an emergency key (Resident 2)?

First Name Last Name
Key holder's phone number (Resident 2)

Area Code Phone Number
Key holders address (Resident 2)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-Signature - Draw the initials of the head of household. This gives us the authority to update the records of each person listed in the form. Use your mouse or finger for a touch sensitive device like a cell phone or tablet. *
THANKS for taking the time to update your information! Please update again any time your information changes. You can call the business office to make changes if you prefer. The number is 954-473-8219.
Please check the box to prove you are human *
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