Round Rock Police Department
Lock Box Program - Member Registration Form
First AND Last Name
Primary Phone #
Format: (000) 000-0000.
Secondary Phone #
Format: (000) 000-0000.
Other Residents in Household
Street Address
City
State
Zip
Lockbox Location
Combo
Pets Inside?
Yes
No
If yes, what kind?
If you have an alarm, do you authorize RRPD to deactivate?
Yes
No
If yes, alarm code:
Medical Conditions
Information will be communicated to first responders if dispatched on your behalf.
EMERGENCY NOTIFICATION INFORMATION
Hospital of Choice
Emergency Contact 1
First & Last Name
Relationship
Phone #
Format: (000) 000-0000.
Secondary Phone #
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State
Zip
Emergency Contact 2
First & Last Name
Relationship
Phone #
Format: (000) 000-0000.
Secondary Phone #
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State
Zip
ADDITIONAL HOUSEHOLD & MEDICAL INFORMATION
Weapons in the Home?
Yes
No
If yes, what kind?
Primary Care Physician
Phone #
Format: (000) 000-0000.
Envelope of Life in Home?
Yes
No
If yes, where?
Location of Medications in Home
Signature of Applicant
Application Received By
Date
-
Month
-
Day
Year
Date
Lockbox Location
Lockbox Code
Installed By
Date of Installation
-
Month
-
Day
Year
Date
Was a lockbox sticker placed near the front door of the residence?
Yes
No
Preview PDF
Submit
Should be Empty: