Medina Township Police Department

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Vacation Form

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Vacation Form

Please fill out the form completely. If "none", please type "no". Thank you.

Begin Watch Date *

Date

Time

End Watch Date *

Date

Time

Address for Watch:

Street Name (Name of street only) *

House Number *

City *

Zip *

Primary Contact

Primary Contact *

Yes
No

First Name *

Last Name *

Cell # *

Email *

Secondary Contact (Spouse/Travel Companion)

First Name *

Last Name *

Cell # *

Local Keyholder (In-Town Emergency Contact)

First Name *

Last Name *

Cell # *

Does the home have an alarm system? *

Yes
No

Will the alarm system be armed? *

Yes
No

Alarm Company Name *

Alarm Company Phone Number *

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

Details *

Any vehicles in the driveway while you're gone? *

Yes
No

Makes, Models, Plates#s *

Other Notes

Disclaimer *

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.

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