Residential Lockbox Program- Application

The Glendale Fire Department's residential lockbox program allows emergency personnel and police to access a key during medical or other emergencies requiring forced entry. This voluntary program is designed for residential properties, where a visible hanging lockbox facilitates access for emergency personnel.

A Senior aged 62 and older, or have a special need, or disability A resident of the City of Glendale Living alone with a chronic illness, at risk of falling, or have a history of emergency calls If you don't live alone, both must have the above criteria *Or are referred by Glendale Fire or Police

The Glendale Fire Department administers the program and assigns lockboxes individually. Information, installation details, and access instructions for each lockbox are securely stored within the emergency dispatch database systems of the City of Glendale Fire and Police Departments. This ensures confidential information storage and facilitates a systematic emergency response. Best of all, the program is free for qualifying residents.

It is important to note that installation of a residential lockbox does not provide homeowners with a "lockout service". Therefore, if a homeowner accidentally locks themselves out of their home, the City of Glendale will not use the lockbox program to grant access to the residence.

Follow these easy steps to get your secure lockbox!

Thoroughly read the information provided above. For questions about the program, please contact the Glendale Fire Department at 623-930-4455.

After submitting your application, please allow 3-5 business days for a Glendale Fire Department staff member or volunteer to contact you.

Upon approval, your residence will be scheduled for lockbox installation. Lockboxes are installed once a month by authorized personnel. Prior to the installation date, you will be contacted to confirm someone will be present during the installation.

*Upon installation, the lockbox can ONLY be used by emergency personnel should you require emergency help.

Full Name*

First NameLast Name

Address*

Address

Unit or Apartment #

CityState

Postal / Zip Code

Home Telephone

Mobile Telephone

Notes:

2. NAMES OF ADDITIONAL PEOPLE LIVING IN HOME

Full Name

First NameLast Name

Full Name

First NameLast Name

Full Name

First NameLast Name

Full Name

First NameLast Name

Emergency Contact #1 Full Name*

First NameLast Name

Emergency Contact #1 Address*

Address

Unit or Apartment #

CityState

Postal / Zip Code

Emergency Contact #1 Phone Number*

Emergency Contact #1 Backup Phone Number

Emergency Contact #2 Full Name

First NameLast Name

Emergency Contact #2 Address

Address

Unit or Apartment #

CityState

Postal / Zip Code

Emergency Contact #2 Phone Number

Emergency Contact #1 Backup Phone Number

Notes:

Pets*

YesNo

Pets- Explain

Alarm*

YesNo

Alarm- Explain

Medical*

YesNo

Medical- Explain

REASON FOR APPLICATION

In consideration of my participation in the residential lock box program, the undersigned, to the fullest extent permitted by law, hereby agrees for the undersigned and the undersigned's heirs and representatives, to indemnify and hold harmless the City of Glendale and their respective employees, officers, and attorneys from and against any and all claims, suits, judgments, losses, damages, personal injuries (including but not limited to death), or liability (including reasonable attorney's fees), directly or indirectly arising from or in connection with the undersigned's participation in the residential lock box program. The undersigned acknowledges and agrees that the undersigned's participation in the residential lock box program is voluntary. The undersigned also understands and agrees that by participating in the residential lock box program is not intended in any way whatsoever to create or impose a special duty on the City of Glendale Fire Department or City of Glendale and their respective employees, officers, and attorneys regarding the undersigned's safety or well-being.

Upon participating in the residential lock box program, the undersigned has voluntarily agreed to assume full responsibility for providing the correct key at all times. Once the residential lock box is installed, first responders can only use the lock box to gain access to the undersigned's home after being summoned to the home for emergency purposes. In the event of a time sensitive situation (e.g. medical emergency, fire, home invasion, etc or malfunction of the lock box, first responders may not be able to, nor have the time to, use the lock box. In those situations, the undersigned agrees that emergency personnel shall have the right to exercise their discretion and gain entry to the undersigned's home using the fastest means possible. However, emergency personnel will use their best efforts to utilize the lock box when time and the situation permits.

PARTICIPATE SIGNATURE*

DATE*

Date

1. Participation in this program is purely voluntary.

2. Lock boxes remain the property of the City of Glendale.

3. Please contact the City of Glendale at 623-930-4455 for:

The master locks or ownership in the residence changed
A new key needs to be placed in the lockbox.
The lockbox in no longer needed or you would like the lockbox to be removed

*This lockbox can only be used in situations by emergency personnel when contacted by resident.

4. You are responsible to report all changes

Name*

First NameLast Name

Glendale Fire Department

RESIDENTIAL LOCKBOX PROGRAM

LOCKBOX PROGRAM APPLICATION

SECURE LOCKBOX PROGRAM RULES OF UNDERSTANDING

PARTICIPATE NAME (PLEASE PRINT)