Operation Reassurance Informational Form

Operation Reassurance is a mission that the Village and Town of Mukwonago Police Departments take very seriously. We want the citizens of our community to feel safe and to be safe. One step in accomplishing this is by the Village and Town Police Departments providing this special service to you.
Although you may choose to become a member of our Operation Reassurance program for as long as you wish, we do have some important guidelines that you must follow to ensure that we can provide you with the best service possible.
1. When you sign up for Operation Reassurance, you are making a commitment that you will call in every day during the time frame you choose below. For example, if you choose to call us during the 9 AM to 11 AM window, then you will be expected to call every day of the week during this time, UNLESS you contact us and let us know that you will not be calling in for some reason. For example, maybe you have scheduled a doctor's appointment or a vacation during your scheduled time. That's fine, just let us know that you will not be calling in. Otherwise, if we do not hear from you, we will assume there could be a problem and we will send someone to your home to check on you.
2. If you fail to call in more than five (5) times, we may discontinue offering this program to you.
Contact Information
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cellular Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Email
Emergency Contact Information
Contact #1 Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Relationship
Does this contact person have keys to your residence?
- Yes
- No
Contact #2 Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Relationship
Does this contact person have keys to your residence?
- Yes
- No
Legal Next of Kin
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Relationship
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Relationship
Medical Information
Doctor's Name
First Last
Doctor's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Doctor's Phone
Miscellaneous Infromation
Pets: Type of Animal(s)
Is your pet friendly?
- Yes
- No
Is there a cage/crate to put them in?
- Yes
- No
What is the location of the cage/crate?
Is there a hidden key?
- Yes
- No
If yes, what is the location of the key?
Do you drive?
- Yes
- No
If yes, please provide the following vehicle information.
Vehicle Make
Vehicle Model
Vehicle Color
License Plate #
Do you attend any programs outside of the home on a daily or weekly basis?
- Yes
- No
If yes, please advise when and where.
What time window, when you call our department, would you like to sign up for?
- 9:00 am to 10:30 am
- 4:30pm to 6:00pm
Download the Medical Emergency Information Form
(We recommend that you download, complete and post this information on your refrigerator. You could also copy this form and carry it in your wallet/purse)
All information if kept confidential and is only used in case of an emergency.
Once you have submitted this form, a member of the Village Police Department or the Town Police Department will meet with you to go over procedures.

By signing and dating this agreement, I am acknowledging my responsibility to call in every day during my time window.
Signature*
Date
Date Format: MM slash DD slash YYYY

Operation Reassurance Informational Form

Contact Information

Emergency Contact Information

Legal Next of Kin

Medical Information

Miscellaneous Infromation