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2. First Name*
3. Last Name*
5. Phone Number*
7. Email*
9. Address1*
11. Address2
13. City*
14. State*
15. Zip*
17. Date of Birth*
18. Sex*

    1. Female
    2. Male
20. If you would like Brighton Police Department and other rescue personnel to have your GARAGE DOOR CODE, please enter that here:
21. If you would like Brighton Police Department and other rescue personnel to have additional ACCESS CODES to enter your home, please enter those here:

    Please include where these access codes should be used. (Ex. 1234, Back Door)

23. Emergency Contact Name*
25. Emergency Contact Phone Number*
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field