LIFE ALARM ACTIVATION FORM

**PLEASE REFER TO OUR "PRIVATE PAY" SECTION TO CHOOSE YOUR DESIRED MONTHLY PAYMENT PLAN PRIOR TO STARTING THIS SECURED FORM. ** ONLY THE FAMILY & FRIENDS PLAN REQUIRES EMERGENCY CONTACT PERSONS' NAME AND CONTACT NUMBER WHEN FILLING OUT THIS FORM. **BY FILLING OUT THIS FORM, YOU AGREE WITH LIFE ALARM SERVICES TERMS AND CONDITIONS AT THE BOTTOM OF THIS PAGE. YOU CAN ALSO CALL OUR OFFICE AT 1-800-780-5433 AND OUR STAFF WILL ASSIST YOU WITH FILLING OUT THIS FORM IF NEEDED.