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2. You must read the program description and requirements BEFORE submitting an application.
   Home Vacation Check Program - description & requirements
4. I have read and understand the Home Vacation Check description and requirements.*

   1. Yes
6. How did you hear about this program?
8. RESIDENT INFORMATION
10. Last Name*
11. First Name*
12. Middle Name

    Full middle name required

13. Date of Birth*
    Example: 01/14/1982
15. House Number*
16. Street Name*
17. ZIP*
19. Home Phone
20. Cell Phone
21. Away Phone

    If known & for emergency contact only

22. Other Phone
24. Email
25. Will you be monitoring this email while on vacation?

    1. Yes
    2. No
27. Away Location/Address (For emergency contact only)
    Examples: 1234 Any St, Yuma, AZ or Cruise ship name, or China, etc.
29. This service is provided for those who are gone a min. of 7 days and a max. of 45 days. Applications MUST be submitted at least 7 days BEFORE departure. We cannot accommodate multiple consecutive vacation check requests.
31. Departure month*
    -- Select One --JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
32. Departure Date*
    -- Select One --12345678910111213141516171819202122232425262728293031
33. Departure Year*
    -- Select One --202220232024
34. Departure Time*
    -- Select One --AMPM
36. Return Month*
    -- Select One --JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
37. Return Date*
    -- Select One --12345678910111213141516171819202122232425262728293031
38. Return Year*
    -- Select One --202220232024
39. Return Time*
    -- Select One --AMPM
41. Local Emergency Contact (key holder) is required.
43. Emergency Contact - Last Name*
44. First Name*
46. Home Phone
47. Cell Phone
48. Work Phone
49. Other Phone
51. Alarm?

    1. Yes
    2. No
52. Audible or Silent?

    1. Audible
    2. Silent
53. Will the alarm activate if the doors are firmly checked?

    1. Yes
    2. No
54. Is the alarm monitored by an alarm company?

    1. Yes
    2. No
56. Name of Alarm Company
57. Alarm Company Phone
58. Can your emergency contact deactivate your alarm?

    1. Yes
    2. No
60. Will you have lights, radio or tv left on timers?

    1. Yes
    2. No
61. Do you want your backyard checked?

    1. Yes
    2. No
62. If the backyard is fenced, how should we gain entry?
64. Is this a gated community?

    1. Yes
    2. No
65. How will we gain access?
67. We strongly recommend you stop your newspaper and mail service while you are gone.
69. If packages or documents are found while you are gone, where would you like them placed? (We accept no responsibility for these items)
71. Will you be leaving a vehicle, or multiple vehicles visible on your property, while you are gone?

    1. Yes
    2. No
73. Vehicle #1
    License plate, Make, Model, Color
74. Location of Vehicle #1
    -- Select One --DrivewayCarportOther
75. Other Location
77. Will you be leaving a 2nd vehicle?

    1. Yes
    2. No
79. Vehicle #2
    License plate, Make, Model, Color
80. Location of Vehicle #2
    -- Select One --DrivewayCarportOther
81. Other Location
83. Will you be leaving a 3rd vehicle?

    1. Yes
    2. No
85. Vehicle #3
    License plate, Make, Model, Color
86. Location of Vehicle #3
    -- Select One --DrivewayCarportOther
87. Other Location
89. In addition to the "Emergency Contact", the following people are authorized to be on/in the property. Examples: Maid service, lawn care, pet care, etc.
91. Name and/or Company Name (1)
92. Phone
93. Alternate Phone
95. Vehicle Description
97. Name and/or Company Name (2)
98. Phone
99. Alternate Phone
101. Vehicle Description
103. Name and/or Company Name (3)
104. Phone
105. Alternate Phone
107. Vehicle Description
109. Special information about the residence or situation that should be known during your absence.
111. Required:*

     By submitting this form, I hereby authorize house checks to be conducted in my absence. I understand and acknowledge that a request for a house check pursuant to this program does not guarantee the safety or security of my property. I further acknowledge that the Eugene Police Department is in no way responsible for my property in my absence and that Seniors on Patrol and Eugene Police may visually and/or physically inspect my premises during their patrols.

     1. Yes
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113. 1. Receive an email copy of this form.
114. Email address

     This field is not part of the form submission.

115. Submit

* indicates a required field