Station Consent Form

This form records a fire department's authorization for Critical Wellness, LLC to send operational text messages to its station and duty phone numbers. It is completed once per department at onboarding, and amended when stations or numbers change.

Department Information

Fire Department or Agency Name

Authorized Representative (Name & Title)

Department Contact Email

Department Contact Phone number

Station numbers authorized to receive messages

List each station and the mobile or duty number that is to receive messages. Use one line per number, and add rows as needed.

Station

Mobile/Duty Number

The undersigned confirms that they are authorized to provide these numbers on behalf of the department, that the numbers are department-issued station or duty lines rather than personal numbers belonging to individual members, and that the department consents to receive the messages described above.

I consent, on behalf of the department named above, to receive text messages from Critical Wellness, LLC as described in this form. I understand that consent is not a condition of any purchase, and that the department may withdraw any number at any time.

Operational session notifications, typically one or two per service day. Message and data rates may apply. Reply STOP to opt out. Full terms.

Signature of authorized representative

Printed Name/Title

Date

Month

Day

Year

What Critical Wellness will send

By providing the numbers above, the department authorizes Critical Wellness, LLC to send operational text messages to those numbers. Messages state the time a crew's wellness session is scheduled on a given day, and give notice that the Critical Wellness provider team has left the previous station and is en route. Messages may include a link to the Critical Wellness website.

Critical Wellness does not send marketing, promotional, or sales messages to these numbers, and does not share them with third parties or affiliates for marketing purposes.

Frequency — Message frequency follows the program schedule. On a service day a station typically receives one or two messages. No messages are sent on days without a scheduled session.

Cost — Critical Wellness does not charge for these messages. Message and data rates may apply under the mobile plan associated with that line.

To stop — Reply STOP to any message to stop further messages to that number. The department may also request removal of any number by contacting Critical Wellness directly.

For help — Reply HELP to any message, or contact Critical Wellness using the details below.

Full terms are published at criticalwellnessfd.com/sms-terms and the privacy policy at criticalwellnessfd.com/privacy-policy.

Contact

Critical Wellness, LLC

Menlo Park, California

Email: info@criticalwellnessfd.com

Phone: (650) 759-2320

Station Consent Form

Department Information

Station numbers authorized to receive messages

What Critical Wellness will send

Contact

Critical Wellness

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