Police Department —

Senior Watch Program

The Poland Township Trustees have sponsored the “Poland Township Senior Watch Program” mainly for the benefit of township’s senior citizens, but others may benefit as well. Shut-ins, wheelchair bound or SSL recipients are some additional examples.

The Poland Township Senior Watch Program application form is available below for download. The completed application can be fax to 330.757.1152 or mail to:

Poland Township Senior Watch Programs
3339 Dobbins Road
Poland, OH 44514

Senior Watch Program application form here: Senior Watch Program application form PDF Download. In addition, you can complete the online version of the form below.

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Poland Township Senior Watch Program Application Form

Please complete the pertinent information for the senior citizen or individual needing Senior Watch services:

Name(*)

Please type your full name.

Address 1(*)

Invalid Input

Address 2

Invalid Input

City(*)

Invalid Input

State(*)

Invalid Input

Zip Code(*)

Invalid Input

Phone(*)

Invalid Input

Cell or Other Phone

Invalid Input

Date of Birth(*)

/ / Invalid Input

Age(*)

Invalid Input

SSN

Invalid Input

Application Requested by:

Requested By(*)

Invalid Input

Relationship(*)

Invalid Input

Your Email(*)

Invalid Input

Your Address 1(*)

Invalid Input

Your Address 2

Invalid Input

Your City(*)

Invalid Input

Your State(*)

Invalid Input

Your Zip Code(*)

Invalid Input

Your Phone or Cell(*)

Invalid Input

Physician Family/General information:

Physician Name(*)

Invalid Input

Physician Phone(*)

Invalid Input

General Health or Illness(*)

Invalid Input

Allergic to medications(*)

Invalid Input

1st Emergency Contact (Family Neighbors/Friends):

Relationship — (1st Contact)(*)

Invalid Input

Address — (1st Contact)(*)

Invalid Input

Address 2 — (1st Contact)

Invalid Input

City — (1st Contact)(*)

Invalid Input

State — (1st Contact)(*)

Invalid Input

Zip Code — (1st Contact)(*)

Invalid Input

Phone or Cell — (1st Contact)(*)

Invalid Input

2nd Emergency Contact (Family Neighbors/Friends):

Relationship — (2nd Contact)

Invalid Input

Address 1 — (2nd Contact)

Invalid Input

Address 2 — (2nd Contact)

Invalid Input

City — (2nd Contact)

Invalid Input

State — (2nd Contact)

Invalid Input

Zip Code — (2nd Contact)

Invalid Input

Phone or Cell — (2nd Contact)

Invalid Input

Last page—Submit Form!

Additional Information (Outside key/lockbox/etc.):

Additional Information

Invalid Input

(*)

Invalid Input

Police Department —

Senior Watch Program

Poland Township Senior Watch Program Application Form

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Police Department — Senior Watch Program

Poland Township Senior Watch Program Application Form

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Police Department —

Senior Watch Program