Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Departure Date *

MM

DD

YYYY

Return Date *

MM

DD

YYYY

Keys left with anyone? *

Yes

No

Home alarmed? *

Yes

No

Will anyone have access to your premises? *

Yes

No

Waiver Acknowledgment *

I hereby waive all claims to damage and/or loss to my person or property which may be caused by any act, or failure to act, of the Crofton Police Department and its personnel, the Crofton Civic Association, its officers, agents, or employees from this requested Home Security Check and I further hereby release and forever discharge and hold harmless the aforementioned same fail to find a burglary, destruction to property, or any other type of incident at the above requested location while a security check is being conducted. I also understand that additional security requests will require additional waivers.

I agree

Date Signed *

MM

DD

YYYY