Chief of Police

       Joseph A. Roark

PELHAM

POLICE DEPARTMENT

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,

 

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 individualís eighteenth birthday.

 

Signature:____________________________________________Date:______________

 

PLEASE SUBMIT COMPLETED FORM DIRECTLY TO THE PELHAM POLICE DEPARTMENT