Forms • Cocoa • CivicEngage

Vacation House Check

Leave This Blank:

RESIDENT INFORMATION
Last Name*	First Name*	Email Address
Street Address*	Home Phone	Cell Phone	Other Phone
Date Leaving*	Date Returning*
NOTE: YOU MUST CALL THE COCOA POLICE DEPARTMENT AND ADVISE WHEN YOU HAVE RETURNED HOME.
LOCAL EMERGENCY CONTACT INFORMATION
Emergency Contact must have key, must be local and has authority to allow Police and/or Fire Services into residence. This person will be responsible for securing the property should there be damage due to burglary, fire, etc.
Last Name*	First Name*	Does contact have house key?*
Street Address*	City*	Phone*
Notes
ALTERNATE CONTACT
Last Name	First Name	Does contact have house key?
Street Address	City	Phone
Notes
VEHICLES LEFT ON PREMISES
VEHICLE #1
Make	Model	Color	License #
Location
VEHICLE #2
Make	Model	Color	License #
Location
PEOPLE WITH PERMISSION TO BE ON PROPERTY
Name	Vehicle Information	Phone
Name	Vehicle Information	Phone
ALARM INFORMATION
Alarm System?*	Audible?*	Alarm Service	Phone
*NOTE* * It is very important that you secure your residence before departing. This includes locking windows, porch access, sheds, etc. * Remember to stop your mail and newspapers or make arrangements for someone to pick them up. * The Cocoa Police Department will not check properties that are for sale or if someone is staying at the house while you’re gone. * This program is not a guarantee that your residence will be under constant surveillance. It will only be checked as manpower and call volume allows.
DISCLAIMER: "The While You’re Away Program is a courtesy service provided by the City of Cocoa to its citizens, and does not constitute a protective services contract, express or implied, between Program participants and the City. I hereby release, waive, discharge and hold harmless the City of Cocoa, its officers, servants, agents, and employees from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or relating to any loss, damage or injury that may sustained by me, or to any property belonging to me, while participating in this Program."
AUTHORIZATION: By submitting this form, I, the homeowner/custodian, hereby acknowledge that I have read and understand the conditions of this program and authorize the Cocoa Police Department to use the information supplied by me in the performance of their official duties.

* indicates required fields.

Live Edit

Contact Us

Follow Us

Helpful Links