MADERA SHERIFF’S OFFICE CITIZENS ON PATROL VACATION CHECK REQUEST AREA:__________ ASSIGNED#______ NAME________________________________________________________________PHONE____________________ ADDRESS_____________________________________________________________CITY______________________ CROSS STREET ___________________________________________________HOUSE COLOR ________________ P.O. BOX _____________________________________________________________________________________ DEPARTURE DATE ____________________TIME:___________RETURN DATE:______________TIME:__________ ALARM YES ___ NO___ NAME AND PHONE NUMBER OF PERSON WHO CAN TURN OFF ALARM (ALARM CO., RELATIVE, FRIEND) _________________________________________ DOG ON PROPERTY: YES___ NO___ ARE GARDENERS, POOL SERVICE OR OTHER SERVICE PEOPLE ALLOWED ON PROPERTY YES__ NO__ NAME ___________________________________________SCHEDULE__________________________________ LIGHTS LEFT ON YES___ NO____ VEHICLES ON PROPERTY YES___NO___ LICENSE #1_________________ LICENSE #2_________________ IN GARAGE YES___NO___ OTHER PEOPLE AUTHORIZED TO BE ON PROPERTY ________________________________________________ EMERGENCY CONTACT NAME _______________________PHONE: HM______________________OTHER___________________ ADDRESS: ______________________________________________________________________________________ RELATIONSHIP__________________________________ KEY TO PROPERTY YES________NO______ ADDITIONAL INFORMATION________________________________________________________________________ ________________________________________________________________________________________________ Vacation checks are not required by Law. As a service to the community the Madera Sheriff's Department offers home vacation checks by trained members of Citizens On Patrol (COP). While you are on vacation your house may be checked by members of COP. Your signature authorizes a member of COP to enter your property to perform this service for you. This agreement is not intended to provide you with any additional law enforcement services, and officers will not check your residence unless a problem is noted by the COP Volunteer. We also request that you notify us when you return from vacation, anytime that the home will be occupied again. *A Vacation House Check form must be filled out in order to participate in this free program. Information that is given by phone will not be accepted. Request is valid for up to 30 days at a time. If you would like longer service, a new form will have to be filled out. YOUR SIGNATURE________________________________________________DATE:______________ RECEIVED BY ___________________________________________________DATE:_______________ THIS REQUEST MUST BE RECEIVED AT LEAST 7 DAYS PRIOR TO YOUR VACATION. Rev June 2013 Mail to: MADERA COUNTY SHERIFF’S DEPT., 14143 Road 28, Madera, CA 93638, ATTN: Crime Prevention