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2. First Name
3. Last Name
5. Address1
7. Address2
9. City
10. State
11. Zip
13. Business Name (If applicable)
15. Date
17. Telephone Number
19. Email
21. Camera Location*

    Please provide a detailed location of the camera(s)

    1. street view
    2. back yard
    3. driveway
    4. parking lot
    5. front door
    6. back door
    7. all 4 sides
23. Disclaimer: By completing this form you agree to these terms of use
    Terms of Use: The goal of the program is to deter crime and promote public safety through collaboration between the South Hadley Police Department and the residents and businesses we are sworn to protect. Accordingly, all registered members agree to the following terms and conditions: Any footage containing or related to criminal activity may be collected by the South Hadley Police Department for use as evidence during any stage of a criminal proceeding. Under no circumstance shall registered members construe that they are acting as an agent and/or employee of the Town of South Hadley and/or the South Hadley Police Department through the program. If necessary, the South Hadley Police Department will contact you directly, using information provided by you, to request the appropriate video surveillance footage. By submitting this information, the registered member understands and agrees to the above policy and terms of use.
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field