Instructions for Filling out MAPS Application

The following information will assist you in filling out the application for your participation in the Sheriff's Medical Alert Program for Seniors (MAPS). Please have the information typed or print clearly. The information entered will be entered exactly as you prepare it. If you are unsure of any of the requested information, please verify it before entering it into the document.

Please read these instructions carefully before filling out the Hunterdon County Medical Alert Program for Seniors (MAPS) application (PDF).

  • Section 1: 
    • Enter your name, beginning with your last name, enter your first name and then enter your middle initial. If you do not have a middle initial, please leave the space blank.
    • Enter your social security number in the space provided.
    • City, state and zip is your post office mailing address.
    • Enter your home telephone number; if you work, enter that number as well.
    • Enter your height and weight. Enter your blood type if it is known.
    • DOB is your Date of Birth.
    • Enter the color of your right eye. Indicate your hair color.
    • Indicate where you are male or female. Describe any tattoos, scars, or other marks which may help to verify your identification.
  • Section 2: Please list the name of one person who you wish to be notified should you be involved in an emergency situation. Indicate how this person is related to your. Enter their address, their home and work telephone numbers.
  • Section 3: Enter the name of the doctor who is responsible for most of your medical needs. Enter the telephone number and address of this physician.
  • Section 4:List any conditions requiring continued physician care. Examples of this are, but not limited to:
    • Alzheimer's, Angina, Asthma, Bleeding Disorder, Diabetes, Hypertension, Leukemia, Pacemaker, Seizure Disorder, Stroke, etc. 
    • Alcoholism and/or Drug Dependency should be noted here.
  • Section 5:Allergies to be noted include, but are not limited to:
    • Aspirin, Penicillin, Sulfa, Tetracycline, Peanuts and other foods, Insect stings, X-ray dyes, Anesthetics, etc.
  • Section 6: Any current medication that is prescribed and taken on a regular basis should be entered here. Dosage information is not required. Examples are medication for hypertension, heart conditions, etc.
  • Section 7: Give the name of your pharmacy, and its telephone number. Ask your pharmacy for the 24-hour number, and if it is different than the regular number, enter it in the place provided. Please include area code.
  • Section 8: Please indicate whether or not you have authorized DNR (Do Not Resuscitate). You must attach a copy of your authorization to your application if you choose to have this authorization honored through the MAPS Program.
  • Section 9 and Section 10: Please indicate whether or not you have a living will, and if you are an organ donor. If the answer to either of these questions is yes, it is recommended that you provide this information to your emergency contact person and/or to your power of attorney, if you have one.
  • Section 11: Please indicate whether or not you have a durable power of attorney. If yes, please provide the name, address and telephone number of this person.
  • Section 12: Please list the name of your medical insurance carrier. List the policy or account number; please list your medicare number. If you are receiving Medicaid, please list Medicaid under Medical Insurance Carrier.
  • Section 13: Here you may list any specific personal information that you feel is important, but for which you did not find a place for elsewhere on the application. This may also be used for additional medical information, family information or other emergency concerns.
  • Section 14: Please read, sign and date the MAPS Application Form.
  • Section 15: If you are filling out this application on behalf of another individual, please sign your name, and state your relationship. This will be helpful if there are inquiries regarding the application information.
  • Section 16: A picture will be placed on file with your application, if desired.
  • Section 17: It is necessary to review your information on an annual basis. Any new or changed information will be updated, and the entry noted. The number to telephone for adding or changing information is 908-806-4276. You are not required to fill out anything in this section at this time.
  • Section 18: This section will be used to note anytime a health care provider or emergency response person requests information from your records. You are not required to fill out anything in this section.

It is recommended that you keep a copy of your application with your personal records, and that a copy be given to your emergency contact person and/or your durable power of attorney.