To be completed by a Law Enforcement Officer who is DIRECTLY working with the person in need.

Are you an AZ POST certified officer and DIRECTLY working with the individual or family? *

**AoP WILL NOT assist if an officer is called out by a Crisis Response Team, Victim Advocate, DCS, another nonprofit, etc., solely to have an officer submit a request to AoP.

Were you called out solely to place a request to Angels on Patrol? *

If yes, who requested you? Please provide name, company/agency and their contact information.

* Officer's should not utilize AoP solely for a "211" issue, but for a "911" issue *

Officer first name *

Officer last name *

Officer's email *

Officer's call back number - (this is for AoP to contact upon receiving request) We don't share your #. *

Agency *

LEO's Badge # - Precinct - Assignment *

Incident Information

Incident # - If applicable

What was the call for service/or reason for LEO contact? *

Homeless Request? Please read ----------We are not an agency that provides motel vouchers for the homeless ----------- REMINDER: AoP is extremely limited when working with the homeless, as most do not require PD (911), but require social services (211). Angels on Patrol is NOT equipped to work with the chronically homeless, especially now, with the homeless crisis.

Does this person/family have a history of homelessness? If yes, PLEASE DO NOT continue submitting the request, and instead provide families facing homelessness with the Family Housing HUB # 602-595-8700 and 211.org *

Current location of person needing assistance *

Information for Individual Being Assisted by this Request

Main Contact's First Name *

Main Contact's Last Name *

Street Address

City

State

Zip Code

Phone Number

Client's Email Address

Gender *

Male

Female

DOB *

Race *

Additional Individuals On-Scene

# of adults requiring assistance *

# of youth requiring assistance *

Additional information you'd like to share with AoP about individual/family/situation, including names and DOB of others present.

Request of Angels on Patrol

What is your request of Angels on Patrol? *

If applicable, list what other resources were sought prior to submitting request to AoP.

After Hours Request - Between (1900-0700 hours Monday - Friday, weekends & holidays)

PLEASE NOTE** OUR AFTER HOURS CARD HAS BEEN ABUSED IN ASSISTING THE CHRONICALLY HOMELESS. We rely on you, the officer, to vet the situation. Did you vet before using the After Hours Card, and it meets AoP's mission to assist with our limited funds? *

We are receiving "frequent flyers" in the middle of the night. PLEASE ASK IF THEY'VE BEEN ASSISTED BY AoP BEFORE YOU SUBMIT REQUEST. If they have, tell them you CAN NOT assist as they've already been assisted by AoP. Thank you for understanding.

Was an After Hours Visa Card used? *

If After Hours card was used, please provide what it was used for. ** If used for a motel: What motel and room #. ** Thank you for returning the AH card and sending a copy of the receipt to accounting@angelsonpatrol.org

White, non-Hispanic	Hispanic
Asian/Pacific	Black, non-Hispanic
Alaskan/Native American	Unknown
Other Other