Register for the Citizen Well-Check Program

  1. General Information
  2. Personal Information
  3. Are you able to drive?*
  4. Hide a Key?*
  5. Do you have pets?*
  6. Do you have a home alarm?*
  7. Primary Contact Information

    (Person to contact if Well-Check participant cannot be reached)

  8. Does this person have a key?*
  9. Release of Liability

    By entering your name below, you promise and agree to release from liability and hold harmless the Town of Holly Springs, the Chief of Police, and their respective representatives. This includes all employees, agents, volunteers and officials from any loss, damage or harm arising out of their acts, omissions or conduct of whatever nature as it pertains to participation by the Chief of Police, his representatives, employees, agents, volunteers and officials in the citizen Well Check Program.

  10. Leave This Blank: