City of Derby

Derby Police Department
Vacation Home Alert Request Form

Attention Property Owners: The intent of the Vacation Home Alert Request Program is to obtain contact information should there be an emergency at your home during your absence. This information will be available to police officers who patrol your neighborhood. In addition, your home could be checked by trained citizen volunteers.

Fill out the form below and when you have rechecked the information to make sure it is correct, hit the submit button. The form will be emailed to the Derby Police Department.

**Please call the Derby Police Department at 788-1557 upon your return and give the dispatcher your I.D. number to clear this vacation home alert request.**

Name:
Phone:
Address:
Email:
Start Date:
Stop Date:
Reason:
ID (DOB):
Residence:
Business:
Other:
Kansas DL #:
Emergency Contacts/Persons with Access to Property
Name:
Address:
Home Phone:
Work Phone:
KEYS:
Yes
No
Name:
Address:
Home Phone:
Work Phone:
KEYS:
Yes:
No:
Property Information
Alarm:
Yes
No
Alarm Co:
Alarm Co Ph:
Pets:
Yes
No
Description:
Lights On:
Yes
No
Constant
Timer
Room:
Times:
Room:
Times:
Vehicles On Property
Year
Make
Model
Color
License Plate
State
Other: