City of Seat Pleasant Police Department

Senior Safety Monitoring Program Application

As a duty of the COPS officer, the senior welfare checks are to engage with the elderly community. The officer assesses the needs of the individual and connects them to available community resources. The officer also engages in conversation regarding current events in the neighborhood with the individual. To request a senior welfare check, please fill out the form below.

For Emergencies: Call 9-1-1

Devan A. Martin Chief of Police

Applicant Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Date of Birth *

format: mm/dd/yyyy

Vehicle Owned *

Medical History or Medical Diagnosis *

*Please list any recent surgeries

Emergency Contacts Information

Name *

First

Last

Relationship *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Name

Relationship

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Authorization: The aforementioned applicant signs this application authorizing the City of Seat Pleasant Police Department to contact and visit the listed address of the registered senior weekly to check their well-being.

Applicant Signature *

First

Last

Date *

Format: mm/dd/yyyy

Please attach a current picture of applicant to application *

City of Seat Pleasant Police Department

Senior Safety Monitoring Program Application

Applicant Information

Emergency Contacts Information

Authorization: The aforementioned applicant signs this application authorizing the City of Seat Pleasant Police Department to contact and visit the listed address of the registered senior weekly to check their well-being.

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