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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?
Self
Loved One
Please fill in your information below
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Phone
*
What is your relationship to the person receiving the device?
*
Applicant Information
Are you a veteran?
*
Yes
No
Are you the spouse of a veteran?
*
Yes
No
Are you the widow of a veteran?
*
Yes
No
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
Phone
*
Date of Birth
*
MM slash DD slash YYYY
Branch of Service
*
Army
Marine Corps
Navy
Air Force
Coast Guard
Years of Service
*
Please enter a number from
1
to
35
.
Dates of Service
*
Annual Income
*
Do you have a home landline?
*
Yes
No
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
*
41010
68295