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PVE-CARES Online Registration Form

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 CARE

Palos Verdes Estates Police Department

PVE-CARES Confidential File Questionnaire 

For New Member Registration  

The Palos Verdes Estates Police Department’s PVE-CARES (Care, Assistance, Resources, Education and Socials) Program is a free service for PVE seniors (65 and older) and dependent adults (18-64). A city sponsored program, staffed with a full time coordinator and community volunteers, working to enrich the lives of our seniors by involving them in the community.

The information provided from this form will be used to create a “Reference File” in a CONFIDENTIAL database. The aim is to act as a “referral hub” and conduit to the Police Department as well as providing education on how to avoid becoming a victim of elder abuse.

• PLEASE COMPLETE ALL ITEMS BELOW •

 

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Palos Verdes Estates Police Department PVE-CARES Confidential File Questionnaire For New Member Registration The Palos Verdes Estates Police Department’s PVE-CARES (Care, Assistance, Resources, Education and Socials) Program is a free service for PVE seniors (65 and older) and dependent adults (18-64). A city sponsored program, staffed with a full time coordinator and community volunteers, working to enrich the lives of our seniors by involving them in the community. The information provided from this form will be used to create a “Reference File” in a CONFIDENTIAL database. The aim is to act as a “referral hub” and conduit to the Police Department as well as providing education on how to avoid becoming a victim of elder abuse. • PLEASE COMPLETE ALL ITEMS BELOW •
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Emergency Contact Information
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Emergency Contact Information
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Are you medically dependent on electricity?
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Are you medically dependent on electricity?
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Do you live alone?
Do you live alone?
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Do you have any immediate needs we can assist you with? Note this registration is not monitored daily.
Do you have any immediate needs we can assist you with? Note this registration is not monitored daily.
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Are you able to drive?
Are you able to drive?
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If no, what is your method of transport?
If no, what is your method of transport?
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Do you have problems with mobility?
Do you have problems with mobility?
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If yes, which aid to you use?
If yes, which aid to you use?
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Do you currently receive assistance from a Caregiver?
Do you currently receive assistance from a Caregiver?
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If yes, select who Caregiver is:
If yes, select who Caregiver is:
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Name of Caregiver and/or Agency Name
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If Caregiver is a paid professional, is the individual who assists you:
If Caregiver is a paid professional, is the individual who assists you:
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What type of assistance could PVE-CARES provide for you?
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Penal Code Section 368 defines Elder Abuse as not only physical abuse, but also includes the
infliction of mental suffering, physical and mental neglect, and theft or embezzlement.

Elder is defined by the Penal Code as anyone 65 years of age or older

PVE-CARES
340 Palos Verdes Drive West • Palos Verdes Estates, CA 90274-1299 • (310) 378-4211

Revised 1/2018

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