THE FOLLOWING INFORMATION IS FOR THE DATABASE ONLY
 AND WILL NOT BE SHARED WITHOUT YOUR PERMISSION.

PLEASE TYPE YOUR INFORMATION IN EACH BLANK:

STREET  NAME:             

HOUSE NUMBER:         

TELEPHONE  NUMBER:

EMERGENCY TELEPHONE NUMBER NAME AND RELATIONSHIP OF CONTACT :       

 EMAIL ADDRESS #1:    

EMAIL ADDRESS #2:     (give only if you want e-mails sent to two different e-mails)

LAST NAME:                 

FIRST NAME:             

SPOUSE'S FIRST NAME 

SPOUSE'S LAST NAME (if different) 

Please type first and last names and relationship of other members of your household.

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

PETS: Our residents call or e-mail us with lost or found pets. With this information an easier, safer, and a quicker return of all pets will be accomplished. Please include color, breed, name, size, gender, and anything to help identify your pet.
 

 If you have a Pet, please describe in box: 

Biennially  we publish and distribute a printed directory to the Kelliwood Terrace residents.  We provide space for you and your spouses name, phone and children's names.

May we have your permission to include your name and your spouses name in our printed directory?   Yes    No 

 If Yes, may we include your telephone number?   Yes    No 

  If Yes, may we include your children's names?    Yes    No     

Also, we maintain a Kelliwood Terrace Website (www.kelliwoodterrace.org) which contains a directory by name and one by address  carrying the resident information.  We provide space for you and your spouses' name and one phone number. Children names are NEVER listed on the web.

May we have your permission to include your name and your spouses name in our website directory?    Yes    No   

If Yes, may we include your telephone number?    Yes    No   

If you have any comments or suggestions, please place in section below.

 Thank you very much for participating in the neighborhood activities,

                                           Tim and Sam Simmons

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