Senior Watch Program

Senior Watch Program

Residence Must Be Located Within Village of East Canton, Ohio
Residents Name
Residents Date of Birth

MonthDayYear
Date
Street Address
East Canton, 44730
Residents Phone Number
Please enter a valid phone number.
Is Address Located Within Village

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

Aultman HospitalCleveland Clinic Mercy Medical CenterAultman Alliance Community HospitalOther
Next of Kin Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number
Please enter a valid phone number.
Additional Phone
Please enter a valid phone number.
Are there advanced directives in place (DNR)

NoYes
Do you have An Additional Next of Kin Contact?

NoYes
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number
Please enter a valid phone number.
Additional Phone Number
Please enter a valid phone number.
If no one responds when village officers conduct a wellness check by knocking on the door or calling the residence, what legal steps should be followed to enter the home? Is there a neighbor, friend, or family member who has a key or access code that would allow lawful entry? Additionally, are there any animals, potentially aggressive pets, or other conditions inside the home that officers should be made aware of before entering?
Authorization for Emergency Entry

By signing below, I authorize the East Canton Village Police Department and/or the Osnaburg Township Fire Department to enter my home only in the event of a life-threatening emergency. This authorization applies when:
- Police have a reasonable belief that immediate entry is necessary to protect life or safety, and reasonable efforts to contact me have been made without success, or there is credible information that someone inside may be in imminent danger.
- This permission is strictly for emergency situations and does not permit entry for non-emergency reasons or searches.
- It allows emergency personnel to act quickly in critical situations where urgent intervention may save lives.
- This authorization will remain in effect until I revoke it in writing.
Signature

Clear
Relationship

Resident/Home OwnerLegal Power of AttorneyOther
Should be Empty: