National Night Out

Event location/address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Start time

:HourMinutesAM/PM Option

End time

:HourMinutesAM/PM Option

Neighborhood Watch Group (if applicable)

Coordinator Information

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

We would like a representative from the police department to visit our location.

Local officials (City Council, Assemble Reps, etc) may visit our location.

Members of the media may visit our location for photo opportunities.

Number of households

Number of people

***IMPORTANT NOTE*** We will do our best to honor any requests for a
representative from the police department and/or local officials. However, due to staffing levels, their attendance is not guaranteed.

Please describe your event plans (activites, entertainment, and/or food)

How did you hear about National Night Out?

Number of children under the age of 12 years old

Due to the large number of applications received last year, we are trying to come up with new ways to make sure as many people who want to participate in National Night Out are able to. Are you ok with the police department connecting you with another party if they are in close proximity to eachother?

The police department often received inquiries from community members asking when National Night Out parties are located when their neighborhood is not participating. Are you ok with the police department providing your party location?

By signing this registration form, you agree that all information is correct and you understand requests for a police department representative and/or local official is not guaranteed.

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