Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

City of Groveland Operation Reach Out Citizen Check-In Program Application Form

  1. Please fill this form out completely. The information on this form will be confidential and used only for the Citizen Check-In Program administration.

  2. Answering Machine

  3. Preferred Day / Time of Call(s):

  4. 1st Preference

  5. 2nd Preference

  6. 3rd Preference

  7. Check answers and explain if necessary

  8. Firearms on premises?

  9. Able to Walk

  10. Live Alone

  11. Keys on premises

  12. Pets on premise

  13. Please provide contact information for at least one person. The person listed first will be the primary contact person, please consider response time in listing contacts. Calls will be made in descending order.

  14. Emergency Contacts

  15. Leave This Blank:

  16. This field is not part of the form submission.