Thank You for Verifying Your Membership

Order Your Connect America PERS

As a member, you are eligible to receive one of the following Connect America PERS at no cost to you.

Mobile PERS

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Mini Mobile PERS

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Smartwatch

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"*" indicates required fields

Select Your PERS

System Options*

Subscriber Information

Full Name*

First Last

Membership ID*

Gender*

Date of Birth*

Service Address*

Street Address Address Line 2 City State ZIP Code

* Please note that we cannot accept PO Boxes

Phone*

Phone Type*

Email

Preferred Language

Shipping Information

Full Name*

First Last

Shipping Address*

Same as Service Address

Street Address Address Line 2 City State ZIP Code

Phone*

Phone Type*

Email

Emergency Contact

Full Name

First Last

Phone

Phone Type

Email

Add 2nd Contact

Add Another

Emergency Contact #2

Full Name

First Last

Phone

Phone Type

Email

Add 3rd Contact

Add Another

Emergency Contact #3

Full Name

First Last

Phone

Phone Type

Email

Add 4th Contact

Add Another

Emergency Contact #4

Full Name

First Last

Phone

Phone Type

Email

To verify your membership by phone or to inquire about other available products, please call us at:

8XX-XXX-XXXX

*Disclaimer: Location accuracy may vary depending on environmental conditions. Fall detection feature does not detect 100% of falls. If able, users should always press their button when they need help

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​Thank You for Verifying Your Membership

Order Your Connect America PERS

Mobile PERS

Mini Mobile PERS

Smartwatch

Select Your PERS

Subscriber Information

Shipping Information

Emergency Contact

Emergency Contact #2

Emergency Contact #3

Emergency Contact #4

8XX-XXX-XXXX

Thank You for Verifying Your Membership