Application

To apply for free medical alert service from BlueStar, please complete the form below. For questions about the requirements to qualify, please click here. For questions or concerns, please contact us at info@bluestarseniorveterans.org.

Are you applying for yourself or a loved one?
Please fill in your information below
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
What is your relationship to the person receiving the device?*
Applicant Information
Are you a veteran?*
Are you the spouse of a veteran?*
Are you the widow of a veteran?*
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email
Phone*
Date of Birth*
MM slash DD slash YYYY
Branch of Service*
Years of Service*
Please enter a number from 1 to 35.
Dates of Service*
Annual Income*
Do you have a home landline?*
Please share your story with us.*
Please tell us how this device will help you.*
Emergency Contact Information
Who should the monitoring center call in the event of an emergency?
Name*
First Last
Phone*
Relationship to You*

22580

Application

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Applicant Information

Emergency Contact Information

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