Emergency Information

Resident's Name:*

Other Residents in Household:

Resident's Address:*

Resident's Phone No.:*

Location of Lock Box:*

Pets inside Household?

Yes

No

Kind?*

Assigned Lock Combination:
(police use only)

Medical Conditions Present (if any)

Condition #1:

Condition #2:

Doctor Name:

Phone No.:

Hospital Name:

Phone No.:

Emergency Notification Information:

Contact #1 Name:

Home Address:

Home Phone:

Work Phone:

Cell Phone:

Other Phone:

Contact #2 Name:

Home Address:

Home Phone:

Work Phone:

Cell Phone:

Other Phone:

I understand that I am participating in a safety program sponsored by the City of Sachse. I hereby authorize the public safety officials (police/fire/ems) to access my residence in response to a need to ensure my safety and welfare. I agree to hold harmless the City of Sachse, its employees, officers and officials in their actions regarding this program.

Printed Name

Signature

Date

Entered By: (police use only)

Date: