SafeHomes Program

To register, fill in the information below, then print this page out and mail to:
WASA SafeHomes Program, P.O. Box 668, Westford, MA  01886
I join the SafeHomes Program - Safe from Alcohol, Safe from Drugs
I will not serve nor will I allow the comsumption of alcohol by youth under the legal drinking age in my home or on my property.
I will not allow parties or gatherings in my home or on my property when I'm not there.
I will not allow the use or presence of any illegal drugs in my home or on my property.
I will provide a secure storage place for fire arms and other potentially hazardous items.  


         Name: 
      Address: 
         City: 
        State:    Zip: 
 Phone Number: 
Student(s) Grade Level: 


Protection for Teenager and Home Pledge:

     I agree to use this service if I'm gone from home (weekend or vacation, etc.) and choose to leave my teen at home during my absence.
I understand that my name, address, phone number, and student grade level will be listed in the SafeHomes Directroy, and I will receive a copy of this directory. 

_________________________________________________  _____________

Signature                                          Date          
Please print this form, sign it, and return to: 
WASA SafeHomes Program, P.O. Box 668, Westford, MA  01886
(To print this page select File, Print in the web browser)

For more information, please contact Tina Grosowsky at 978-399-2528

Return to the SafeHomes Program Page