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VACATION CHECKS FROM DATES ____________ -______________

PERSONAL INFORMATION:

NAME: _______________________________________________ DOB: _________________________

ADDRESS: ____________________________________________________________________________

PHONE: _______________________________________ CELL PHONE: ____________________________

EMERGENCY/BEST NUMBER(S) TO REACH: ________________________________________________

LIGHTS/PETS

ANY LIGHTS LEFT ON? __________________________ LIGHTS ON TIMER? ________________________

ANY PETS INSIDE HOME? _______________________ TYPE OF PETS (IF YES)? _____________________

BACKYARD

GATE SECURED?

WHO HAS GATE KEY IF LOCKED?

VEHICLES INFORMATION - LEFT AT THIS ADDRESS – VEH, GOLF CARTS, MOTORCYCLES, ETC

1. ___________________________________________________________________________

2. ___________________________________________________________________________

EMERGENCY CONTACT (HOUSESITTER)

DO YOU HAVE A NEIGHBOR, FRIEND, RELATIVE WE CAN CALL IN AN EMERGENCY?

DO THEY HAVE A KEY TO YOUR HOME OR PASS CODE TO THE ALARM?

ALARM SYSTEM? ___________________________________

ALARM COMPANY? _________________________________

ADDITIONAL INFO

ANY ADDITIONAL INFORMATION YOU FEEL WE (POLICE) SHOULD KNOW ABOUT BEFORE HAND OR

TO KEEP AND EYE OUT FOR?
(FOR DISPATCH TO READ IF THEY ARE NOT COMING TO PD TO COMPLETE FORM. THIS WAY

THE AGREEMENT IS ON RECORDED TELEPHONE LINE)

(STATE REQUESTER NAME) The undersigned does hereby grant and request the Buckeye Police

Department and its Officers/Volunteers to visually check upon the property listed above. The

undersigned does hereby agree to hold harmless the Town of Buckeye; its employees, and agents for

any claim for personal injury, loss or damage to property that may be suffered by the undersigned,

through any action or lack thereof, by a representative of the Town of Buckeye. Further, the

undersigned understands and agrees that this is a voluntary, free service and does not create a special

duty upon the town, will be provided only as time is available, and no guarantee is made nor assurance

given against loss, theft, or damage to premises. The undersigned does hereby agree to secure the

premises when leaving and take whatever security measures at his/her disposal to cooperate in

preventing crime, fire or other incidents from occurring. The undersigned has noted any conditions that

will assist the police during these checks and will notify the Buckeye Police Department when he/she

returns.