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Americans with Disabilities Act
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You Are Not Alone (YANA) Program
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Alternate Phone Number
Alternate or Emergency Contacts:
Please indicate contact information for relative, friends or someone we may contact in case we have questions or concerns regarding YANA visits:
Alternate/Emergency Contact #1 - Name
Contact #1 Phone
Alternate/Emergency Contact #2 - Name
Contact #2 Phone
Health Information You Would Like To Share With Us:
Electronic Signature Agreement
I agree that all above information is accurate. I also agree to allow Orange Police Department Personnel conduct Y.A.N.A. checks at my residence. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
How did you hear about the YANA Program?
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Our Orange Publication
An OPD Representative (paid staff, volunteer, etc.)
Another YANA Participant
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