*** For emergencies, please call 911; non-emergency: (714) 754-5252.

The Neighborhood Watch application is needed to start a Neighborhood Watch group. It serves to provide the Costa Mesa Police Department the necessary information to register a group and assist the group in its efforts to set up meetings and other Neighborhood Watch activities.

 

Section 1: Neighborhood Watch Contact Information

1

Block Captain Information

Block Captain Information

Name (Last, First)	Current Address:	City:
State:	Zip Code:	Home Phone:
Work Phone:	Cell Phone:	Email Address:

2

Block Co-Captain Information

Block Co-Captain Information

Name (Last, First)	Current Address:	City:
State:	Zip Code:	Home Phone:
Work Phone:	Cell Phone:	Email Address:

3

Neighborhood Association Information

Neighborhood Association Information

Name of Neighborhood Home Owners Association Supported:

Name of Neighborhood Watch Group:

Section 2: Neighborhood Watch Group Geographical Information

4

Describe the Geographical Boundaries and category (single family residence, multiple family or mobile home) of Your Neighborhood Watch:

Describe the Geographical Boundaries and category (single family residence, multiple family or mobile home) of Your Neighborhood Watch:

5

Approximate Number of homes, apartments, condos, etc in your Neighborhood Watch:

Approximate Number of homes, apartments, condos, etc in your Neighborhood Watch:

Section 3: Neighborhood Watch Group Information

We encourage all Neighborhood Watch Groups to register one email address so that we can communicate quickly with each group. Please identify one person in your Neighborhood Watch group with an email address who will accept broadcast messages about Crime Prevention initiatives.

Neighborhood Watch Group Email:

6

In order to qualify as a Neighborhood Watch, 10 member residents must agree to be a part of the original group. Please list these 10 individuals below:

In order to qualify as a Neighborhood Watch, 10 member residents must agree to be a part of the original group. Please list these 10 individuals below:

Name

Address:

Phone #:

Signature/Date:

7

 

Name

Address:

Phone #:

Signature/Date:

8

 

Name

Address:

Phone #:

Signature/Date:

9

 

Name

Address:

Phone #:

Signature/Date:

10

 

Name

Address:

Phone #:

Signature/Date:

11

 

Name

Address:

Phone #:

Signature/Date:

12

 

Name

Address:

Phone #:

Signature/Date:

13

 

Name

Address:

Phone #:

Signature/Date:

14

 

Name

Address:

Phone #:

Signature/Date:

15

 

Name

Address:

Phone #:

Signature/Date:

Section 4: Agreement

16

I affirm the information stated above is true and correct:

 *

I affirm the information stated above is true and correct:

I am waiving my signature to submit this form electronically to the City.

First & Last Name:

Date:

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