Riverside Police Department Y.A.N.A. Application

You Are Not Alone (Y.A.N.A) Application

Please complete the application as best you can. If you need assistance completing the application or you have questions, please contact Jennie Pauli by email at jpauli@riversideca.gov.
Select position for which you are applying for:*

Volunteer CallerProgram Participant
Applicant Information

Please complete below for both Volunteer Caller and Program Participant applicants
Applicant Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
DOB*

MonthDayYear
Date of Birth
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email*
example@example.com
Preferred Language
If not English, please list language
Premise Information

Please answer all question below for Program Participant Applications
Type of Residence

HouseApartmentAssisted Living
Apartment/Facility Name
Pets/Animals

YesNo
How Many and What Type?
Example: 2 dogs, 3 cats and 1 bird
Firearms

YesNo
What Type and Location?
Example: 2 handguns stored in the closet
Alarm?

YesNo
Company & Phone
Example: ADT Service (951) 123-4567
Emergency Contact Information

Please provide information for (2) emergency contacts. (Preferably someone you can contact regularly)
Emergency Contact Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Relationship
Parent, Sibling, Friend, Cousin, Etc.
Access information

Spare KeyGate CodeAlarm Code
Emergency Contact Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Contact Relationship
Parent, Sibling, Friend, Cousin, Etc.
Access information

Spare KeyGate CodeAlarm Code
Call Information

What day(s) and time(s) would you prefer to be contacted?
Preferred Day For Contact (Select all that apply)

MondayTuesdayWednesdayThursdayFriday
Preferred Time of Day
Example: Morning after 9:00 A.M.
Health Information
Please list any health conditions or concerns you want us to be aware of:
Other
Please list any other concerns or information you want us to be aware of:
Today

MonthDayYear
Date
Age - days
Age - years
Should be Empty:

You Are Not Alone (Y.A.N.A) Application

Applicant Information

Premise Information

Emergency Contact Information

Call Information

Health Information

Other