“The Communicator”
The Village of Deerfield’s Rapid Notification System
Opt in / Opt out Information Form

**This information is considered confidential and will not be shared with any third parties.

Last Name:

First Name:

Street Address:

City:

Primary Phone Number:

Is this a Business or Residence?

Business Residence

Do wish to Opt In or Opt Out?

Opt In Opt Out

Signature (Please type your name)

Date Created:

05/09/2008

If you have any questions regarding the system, please contact the Deerfield Police Department 847-945-8636.

©2003 Village of Deerfield. All rights reserved.