Enroll a Participant — BenAdaptive AI

Complete this form to enroll a senior in the BenAdaptive AI wellness check calling program. Required fields are marked with *.

Participant information

Full name *Preferred nameDate of birthPhone number *Email addressPreferred languageStreet addressCity

StateZIP code

Preferred call time

Preferred days of week

CountySponsoring agency

Emergency contacts

Primary contact name *RelationshipPhone numberEmail

Secondary contact (optional)

NameRelationshipPhoneEmail

Escalation priority (who should be called first if a check fails?)

Tap in the desired order. Tap again to remove.

Wellness check preferences

Daily wellness call — A scheduled friendly check-in.Medication reminderHydration reminderAppointment reminderCustom reminder notes

Voice recording

Upload an audio file (MP3, WAV, M4A, AAC) or record directly. Uploaded recordings may be used to create a personalized AI voice for wellness check calls.

Upload audio file

…or record from your microphone

Consent & authorization

I consent to receive automated wellness check calls. *I consent to receive AI-generated voice calls. *I authorize BenAdaptive AI to notify my emergency contacts if a wellness concern is detected.I authorize call recording and transcription for quality and safety.I acknowledge the Privacy Policy. *I acknowledge the Terms of Service. *

Voice consent recording (read aloud: "I consent to receive automated wellness check calls from BenAdaptive AI.")

Electronic signature (type full name) *Date signed

Participant enrollment

Participant information

Emergency contacts

Wellness check preferences

Voice recording

Consent & authorization