Mequon Cares Registration Form

form.antibot { display: none !important; } You must have JavaScript enabled to use this form.

Contact Information

First Name *

Last Name *

Phone Number *

Address *

City, State, Zip Code *

Emergency Contact Information

What is the name and phone number for an emergency contact? *

What is your doctor's name and phone number?

What is your clergy's name and phone number?

Are you taking medications? Yes/No, If yes, What types?

What is the name and phone number of a trusted neighbor?

If you drive a vehicle, what is your plate number?

If you have a hidden key or a code to get into your residence, where is the key located or what is your entry code?

By selecting "YES" below, I understand that if I don't call the Mequon Police Department by noon each day, they will attempt to contact me and that may include, as a last resort, forcing entry to my residence. I further understand that if damage is caused by the entry, neither the Mequon Police Department nor the City of Mequon will be held liable. I will be responsible for the costs of repair. *

YES

Is there any additional information you want to provide us with?

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

What code is in the image? *

Enter the characters shown in the image.

Search

Mequon Cares Registration Form

Contact Information