Parental House Check Request Form

This form notifies the Keene Police Department that you will be out of town and that children under the age of 21 remain in the home during your absence. Keene police officers, subsequent to this request, will make every attempt to patrol your neighborhood looking for evidence of underage drinking and other crimes or violations that may be occurring on your property in your absence. If such activity is observed, officers will investigate and follow established Departmental and legal procedures to intervene or take action as the situation or applicable law dictates. Utilizing the contact numbers provided below, the officer(s) will attempt to contact you and inform you of any situation they find that requires police intervention. Please understand that this may be well after the situation is handled or stabilized. Also understand that the Keene Police Department may not be able to respond and/or check your residence during the timeframes indicated due to other calls for service. In an effort to combat this, we would urge you to notify your neighbors of your absence and the existence of this request form.

Parent/Guardian Requesting House Check

First Last

Homeowner's Name (if different)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work/Cell

Phone Number to be reached at while traveling

Emergency Contact (local)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Names and ages of children remaining in the home

Potential hazards on property

Are cars parked in the driveway?

Yes

If yes, please list

Make

Model

Color

License Plate