Key Control Number_______________(completed by records clerk)

Emergency Family Contacts Continued

#2
Name_________________________________Home Phone #____________________________________

Cell Phone#____________________________Address_________________________________________

Work Phone#___________________________Relationship______________________________________

Check the One Which Applies

_________I do want the Village of Worth Police Department to come to my home and check on me if I do
not call in each day by 10:00 AM. I have provided a key for entry to my home if I can not be reached. This
will be done only after notifiying my Emergency contact and under the supervision of a Police Supervisor.

_________I do not want the Worth Police to come into my home if I can not be reached. Calls to my
Emergency contacts will be made, and they will enter my home or authorize forced entry if they deem it
necessary. I have provided no key to the police.


Signature of Resident_________________________________________Date__________________________

Signature of Witnessing Emergency Contact___________________________________________________

(Check) Contact#1_______or #2_________ Date_________________________________

(Page 2 of 2)

Print, complete, and bring into the Worth Police Department front desk.