Chief of Police
Joseph A. Roark
14 VILLAGE GREEN
PELHAM, NEW HAMPSHIRE 03076
Telephone (603) 635-2411 Fax (603) 635-6959
To Whom It May Concern,
Please be advised that as the parent or legal guardian of the following individual,
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:
RELATIONSHIP TO INDIVIDUAL:_____________________________________
This request will automatically expire on the above named individualís eighteenth birthday.
PLEASE SUBMIT COMPLETED FORM DIRECTLY TO THE PELHAM POLICE DEPARTMENT