To Whom It May Concern,

Please be advised that as the parent or legal guardian of the following individual,

NAME______________________________________ DOB__________

Social Security #:___________________________ Sex:_______ Race:_______________

I would like to be contacted by a representative of the police department any time said individual comes in contact with the Pelham Police Department in an official capacity.

Furthermore, I understand that there may be times when I may not be contacted due to certain sensitive instances where privacy may be necessary and/or required by law.

My contact information is as follows:

NAME(S):__________________________________________________________

RELATIONSHIP TO INDIVIDUAL:_____________________________________

ADDRESS:_________________________________________________________

HOME TELEPHONE:_______________________

BUSINESS TELEPHONE:_______________________

CELLULAR TELEPHONE:______________________

E-MAIL ADDRESS:__________________________________________

            This request will automatically expire on the above named individual’s eighteenth birthday.

Signature:____________________________________________Date:______________

PLEASE SUBMIT COMPLETED FORM DIRECTLY TO THE PELHAM POLICE DEPARTMENT