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2. Please Note:

   Requests are only processed Monday through Friday between the hours of 8 am and 4:30 pm. Requests are not processed on observed holidays. Any requests submitted outside of the advertised days and times will not be processed until the next business day.

4. Last Name*
5. First Name*
6. Middle Initial
8. Home Address*
10. Home Phone Number
11. Other Phone Number
13. E-mail Address
15. Reason for Application*

    1. I am 55 years of age or older and live alone or am alone on a frequent basis.
    2. I have a medical condition that is potentially incapacitating and live alone or I am alone on a frequent basis.
17. Describe Your Medical Condition*
19. Doctor's Name
20. Phone Number
24. Emergency Contact 1
26. Name
27. Relationship
29. Home Address
30. Phone Number
34. Name
35. Relationship
37. Home Address
38. Phone Number
43. Liability Release

    In consideration of my participation in the Lock Box Program, the undersigned, to the fullest extent permitted by law, hereby agrees for the undersigned and the undersigned's heirs and representatives, to indemnify and hold harmless the City of Lake Mary and Seminole County and their respective employees, officers, and attorneys from and against all claims, losses, damages, personal injuries (including but not limited to death), or liability (including reasonable attorney's fees), directly or indirectly arising from the undersigned's participation in the Lock Box Program. The undersigned acknowledges and agrees that the undersigned's participation in the Lock Box Program is voluntary and that said Program is being offered only as a courtesy. I also understand and agree that the Lock Box Program is not intended in any way whatsoever to create or impose a special duty on the City of Lake Mary and Seminole County and their respective employees, officers, and attorneys regarding the undersigned's safety or well-being.

45. Conditions

    Under the Lock Box Program, the undersigned has voluntarily agreed to participate in the program and assumes full responsibility for providing the correct key at all times. Once the lock box is installed, fire and police emergency personnel can only use the lock box to gain access to the undersigned's home after being summoned to the home for emergency purposes. In the event of a time sensitive situation (e.g. medical emergency, fire, home invasion, etc.) or malfunction of the lock box, fire and police personnel may not be able to, nor have the time to, use the lock box system. In those situations, the undersigned agrees that emergency personnel shall have the right to exercise their discretion and gain entry to the undersigned's home by the fastest means possible. However, emergency personnel will use their best efforts to utilize the lock box when time and the situation permits.

47. Disclaimer

    Each resident (over the age of 18 years) at the home address listed above is required to sign and date this agreement. By typing your name in this field you are submitting via an electronic signature.

49. Contact 1 Signature

    (typed name)

50. Date
    Date
52. Please Note

    If the lock box is no longer needed or the key to your home changes, please call the program coordinator at 407-585-1305 so that we can remove it or change the key placed in the lock box. Thank you.

54. Contact 2 Signature

    (typed name)

55. Date
    Date
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field