• Requests must be received 7 days prior to departure and may not exceed 30 consecutive days.
  • We are unable to service homes with on-site houseguests.
  • If you return BEFORE your stated return date, please call (916) 746-1052.
Vacation House Check Form



Departure Date:                  Return Date:
Last Name:           First Name:
Street Address:   Roseville, CA  Zip Code:
Home Phone:    Cell Phone:     Email:
Last Name, First Name:    Address:   
Check the YES or NO response to the following questions:
    Vehicle(s) left in the driveway.
Make:  Model:  Color:  License Plate: 

    All doors and windows closed and locked? Comment, if needed:

    All exterior gates locked? (Highly recommended) Comment, if needed: 

    Lights or radio left on, or on timers? (Highly recommended) Comment, if needed: 

  Dogs on property have backyard access? Name(s):   Breed(s):

    Anyone with keys to your home? Name:   Telephone: 


Exterieor service provider: gardner, pool, maintenance, etc. 

Days of week:   Time of day/vehicle description:  


Interior service provider: pet feeding, plant watering, etc.

Days of week:   Time of day/vehicle description:


I understand vacation checks/safety patrols will be performed on a random basis as staffing and time permit. Any application may be denied due to history at the residence. My signature on this form releases the City of Roseville, the Roseville Police Department, and the C.O.P. volunteer of all liability for any loss of property or damage that may occur during the aforementioned time period.


 * By checking this box, I understand that I am providing my digital signature. I acknowledge and agree to all of the foregoing, and certify that the information I have provided is completely accurate.


Homeowner/ Resident Signature:            Date: 
Received App.: Yes   No By:
Premise Check: Yes   No By:
Contact Homeowner: Yes   No By:
Dispatch Notified : Yes   No By:

Security Measure