Follow the steps to complete your enrollment form online.

1. Click the ‘Get Form’ button to access the enrollment form and open it in your preferred document editor.
2. Begin by filling in your name in the designated space at the top of the form.
3. Choose your gender by marking the appropriate box: Female or Male.
4. Enter your date of birth, home phone number, and cell phone number in the provided fields.
5. Fill in your complete address, including city, state, and zip code.
6. Indicate your race by circling the category that best describes you.
7. Select the days of the week when you would prefer to receive a call by filling in the corresponding spaces.
8. Circle the time periods during which you are available to receive calls.
9. List two individuals along with their contact information who may be called if you are unreachable. This should include your apartment manager, if applicable.
10. If you are part of a Community Treatment Team (CTT), answer yes or no and provide the requested details if applicable.
11. Please answer whether you live alone or with others, and if it is permissible to leave a message on your answering machine.
12. Describe how the call program can support you in specific areas of your life.
13. Provide information about your preferred hospital for emergencies.
14. Indicate if you have any type of Medical Assistance by checking the applicable options and providing your Medical Assistance number if yes.
15. Share how you learned about the program by marking the relevant option from the provided list.
16. Review the statement below the contact information and sign and date it to verify your enrollment.
17. If someone else is assisting you with the form, note their relationship and contact information.
18. Once you complete the form, save your changes, and choose to download, print, or share the completed form as needed.

Begin completing your PA PSAN Warm And Friendly Call Program Enrollment Form online today!