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2. Vacation Watch Number
4. Date and Time Received
   Date and Time Received

   Date and Time Received
6. Resident Name
8. Resident Address
10. Resident Hone Phone Number
11. Cell Phone Number
13. Departure Date
    Departure Date
14. Return Date
    Return Date
16. Emergency Contact Name
18. Emergency Contact Phone Number
19. Has Key?
21. Alarm

    1. Yes
    2. No
22. Timers

    1. Yes
    2. No
23. Locations
25. Vehicles on Premise

    1. Garage
    2. Driveway
26. Make, Model, License Plate
28. Person/Persons remaining on Premise

    1. Yes
    2. No
29. Name and Age
31. Comments
33. Note:
    THE UNDERSIGNED ACKNOWLEDGES THAT THE IHPPD VACATION HOUSE WATCH PROGRAM IS VOLUNTARY, & IS NOT CONTRACTUAL. PARTICIPATION IN THE PROGRAM DOES NOT ASSURE ANY PARTICULAR LEVEL OF POLICE PROTECTION; THAT SUCH PARTICIPATION DOES NOT CREATE ANY SPECIAL DUTY TOWARD THE UNDERSIGNED ON THE PART OF THE VILLAGE, ITS OFFICERS OR AGENTS; AND THAT THE UNDERSIGNED HOLDS THE IHPPD HARMLESS FOR ANY CLAIMS ARISING OUT OF ANY NATURE OCCURRING ON OR ABOUT OUR PROPERTY WHILE WE ARE ON VACATION.
35. Signature

    By checking this box, I authorize my signature.

    1. Signature
36. Date
    Date
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field