Medina Township Police Department
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Vacation Form
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Vacation Form
Begin Watch Date *:
End Watch Date *:
Address for Watch:
Street Name (Name of street only) *:
House Number *:
City *:
Zip *:
Primary Contact
Primary Contact *:
Yes
No
First Name *:
Last Name *:
Cell # *:
Vacation Landline #:
Secondary Contact (Spouse/Travel Companion)
First Name *:
Last Name :
Cell # *:
Vacation Landline #:
Local Keyholder (In-Town Emergency Contact)
First Name *:
Last Name *:
Cell # *:
Landline #:
Interior Lights on?:
Yes
No
On all the time:
On timers:
Exterior Lights on?:
Yes
No
On all the time:
On timers:
Any Contractors/Tradesmen on premises while you're away?:
Yes
No
Any vehicles in the driveway while you're gone?:
Yes
No
Makes, Models, Plates#s:
Does the home have an alarm system?:
Yes
No
Will the alarm system be armed?:
Yes
No
Other Notes:
Enter the code:
I understand that if I submit a vacation watch less than 5 business days prior to my departure, and/or I submit a vacation watch on a weekend, my vacation watch will be entered into the system on the next business day, which may delay vacation watch service. I understand that vacation watches are being processed by administrative staff who are only in the office on weekdays, and are not in the office on weekends, holidays, and sick days.