charmeckem@charlottenc.gov
500 Dalton Avenue Charlotte, NC 28206
704-336-2412
I acknowledge that a signed release authorization form is on file at the following county location:
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Full Name
Sex
Physical Address
Home Phone Capabilities
Cell Phone Capabilities
Mailing Address (if different)
Living Situation
Conditions- Please select all that apply
Emergency Contact Name
Physician Name
Physician Address
Pet #1
Is this pet a service animal? If yes, please explain.
Pet #2
Pet #3
Pet #4