Senior Watch Program

Senior Watch Program

For Official Use Only Eligibility Determined by Police Chief Thomas Hinerman
Name
Date of Application

MonthDayYear
Address
Street Address
Is your address located within the Village of East Canton limits?

YesNo
Thank you for your inquiry; however, this service is only available to Village of East Canton residents.
Resident's Date of Birth

MonthDayYear
Home Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Primary Care Physican
Physican Name
Physician Phone
Please enter a valid phone number.
Physician Address

Street Address

Street Address

CityState

Zip Code
Please List All Relevant Health Concerns
Preferred Hospital

Aultman HospitalAultman Alliance Community HospitalCleveland Clinic (Cleveland)Cleveland Clinic Mercy Medical CenterOther
Are there advanced directives in place (DNR)

YesNo
How would you like senior check to be performed:

Phone Call To Make an Initial Contact (If No Contact OnSite Visit)On-Site Visit WeeklyDaily if PossibleRandomOther
If there is no answer when the officer knocks on the door or calls the residence, what steps should the officer take to legally enter the home? Does a neighbor or friend have a key or access code that would allow entry? Should the officer be aware of any animals or aggressive pets in the home prior to entering?
Are You Applying For Yourself?

YesNo
Person Making Request
Name
Relationship
Address

Street Address

Street Address

CityState

Zip Code
Mobile Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Are you the Designated Emergency Contact?

YesNo
Emergency Contact
Emergency Contact Phone
Please enter a valid phone number.
Second Emergency Contact
Second Emergency Contact Phone
Please enter a valid phone number.
By signing below, I hereby authorize the East Canton Village Police Department and/or the Osnaburg Township Fire Department to enter my home in the event that the police have a reasonable belief that there is a life-threatening or emergency situation present that requires immediate entry for safety purposes. This authorization applies only when police have made reasonable efforts to contact me and receive no response, or have information indicating someone inside may be in imminent danger. Entry is solely for emergency response and safety purposes. This authorization does not allow non-emergency entry or searches. It enables police and fire personnel to swiftly assist residents in potential life-or-death situations when urgent action is critical. This authorization will remain in effect indefinitely unless revoked by me in writing.
Signature

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Relationship

Owner of HomeLegal Power of Attorney (Attach Copy of POA)
Should be Empty:

Senior Watch Program

Thank you for your inquiry; however, this service is only available to Village of East Canton residents.

Person Making Request