Skip to Main Content
Loading
Loading
Government
Departments
Community
How Do I...
Form Center
Search Forms:
Search Forms
Select a Category
All Categories
Code Enforcement
Contact Township
Lock for Life
Open Records
Police Department
Shade Tree Commission
By
signing in or creating an account
, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
Lock for Life
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
Steps
1.
Step One
This section is complete
This section is incomplete
2.
Step Two
This section is complete
This section is incomplete
Step One
Lock for Life is a program available through the Whitpain Township Police Department. It is intended to provide Police, Fire, and Emergency Medical Services Personnel access to your residence in the event of an emergency where you are unable to open the door.
First Name
*
Last Name
*
Address
*
Street Address
City
*
State
*
Postal / Zip Code
*
Country
*
Phone Number
*
Email Address
Reason for Application
Checkboxes
I am 55 years of age or older and live alone or am alone on a frequent basis.
I have a medical condition that is potentially incapacitating and live alone or am alone on a frequent basis.
Other Reason (Describe below) - Note: Execptions to the above requirements will be considered on a case by case basis. If you feel you would benefit from the program, please apply.
Describe Other Reason
Continue
Step Two
Doctor's Information
Doctor's Name
Doctor's Phone Number
Emergency Contact
Emergency Contact #1
Please provide contact information for an emergency contact.
Emergency Contact #1 Name
*
Emergency Contact #1 Phone
*
Emergency Contact #1 Address
*
Relationship to Emergency Contact #1
*
Emergency Contact #2
Please provide contact information for an emergency contact.
Emergency Contact #2 Name
Emergency Contact #2 Address
Emergency Contact #2 Phone
Relationship to Emergency Contact #2
By participating in the Lock for Life Program I authorize the Whitpain Township Police Department and/or the Centre Square Fire Department, Second Alarmers Rescue Squad to enter my residence for emergency purposes only. I assume all responsibility for providing the correct key and agree to hold harmless the above entities.
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
Submit
|
Go Back
* indicates a required field
Arrow Left
Arrow Right
[]
Slideshow Left Arrow
Slideshow Right Arrow