MRSG

LIFE PRESERVATION MODEL SYSTEMS

Registration Request Form

All registrations are reviewed and approved before access is granted.

1. Info

2. Agreements

3. Security

Section 1 — Applicant Information

Full Legal Name (First, Middle, Last) *

Organization Name (if applicable)

Title / Role

Primary Email Address * (used for approval & credentials)

Mobile Phone Number

Promo / Authorization Code (Optional)

City

State

Section 2 — System Access Selection *

Select one primary package:

MooreConnect – Autism / Cognitive Care Package

$20/month

Citizens Package – With Brain

$11/month

Citizens Package – Without Brain

$10/month

Complete System Access

Full Access

Administrator Package

$10,000/year

Individual Interface Licensing

À La Carte

Section 4 — MooreConnect Applicants

Who will the system support?

ChildTeenAdultSenior

Primary Cognitive Consideration (select all that apply):

Autism SpectrumDementiaAlzheimer'sCognitive ImpairmentNon-VerbalSensory SensitivityElopement RiskOther

Will you require Trusted Contacts activated?

YesNo

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The Moore Resource & Strategy Group · Shawn@themr-sg.com · (414) 865-MRSG