Please call Cedarburg Police Department at 375-7622 by noon every day.Please advise the police station if you are leaving your residence for vacation or hospitalization for any length of time. Name: * Date of Birth: * Address: * Telephone: * Email: * Doctor's Name: Doctor's Phone: Clergy Name: Clergy Phone: Neighbor Name: Neighbor Phone: Next of Kin #1, Name: Next of Kin #1, Phone: Next of Kin #2, Name: Next of Kin #2, Phone: Are You Taking Any Medications? * - Select -NoYes If Yes, Describe the Medications You Are Taking: * Do You Drive a Vehicle? * - Select -NoYes If Yes, Please Provide Your License Plate: * Miscellaneous Information: * Leave this field blank