Sign up to join the 2016-17 Northampton SAFE HOMES Directory!
The Northampton Prevention Coalition SAFE HOMES program empowers parents and guardians to create a safe environment for their teens and their teens’ friends by setting clear expectations about drug and alcohol use in their homes.

By filling out the form below, you are pledging:

• I will not serve or allow minors to consume alcohol or other drugs in my home.
• I will actively supervise parties/gatherings in my home.
• I am open to communication with other parents in an effort to create a safer community for our children.

Parent/Guardian Information
If your child has multiple households, please encourage all parents/guardians to participate.
1. Parent/Guardian FIRST NAME *
Your answer
Parent Guardian LAST NAME *
Your answer
Street Address *
(e.g. 123 Main Street or 456 Your Road)
Your answer
City/Town *
Your answer
Phone Number *
(preferred)
Your answer
Email Address *
(not required but helpful)
Your answer
2. Other Parent/Guardian FIRST NAME
Your answer
Other Parent Guardian LAST NAME
Your answer
Street Address
(e.g. 123 Main Street or 456 Your Road)
Your answer
City/Town
Your answer
Phone Number
(preferred)
Your answer
Email Address
Your answer
Child's Information
Please list each child in grades 6-12 separately.
1. Child's FIRST NAME *
Your answer
Child's Last Name *
Your answer
Child's Grade *
Child's School *
2. Child's FIRST NAME
Your answer
Child's Last Name
Your answer
Child's Grade
Child's School
3. Child's FIRST NAME
Your answer
Child's Last Name
Your answer
Child's Grade
Child's School
4. Child's FIRST NAME
Your answer
Child's Last Name
Your answer
Child's Grade
Child's School
Agreement to Join SAFE HOMES *
Required
Thank you for registering as a SAFE HOME!
This information will not be used or distributed for any other purpose. SAFE HOMES agreements are not legally binding, but are statements of concern and intent. SAFE HOMES and its members are not able to guarantee or enforce compliance.
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