Illinois Premise Alert Program Enrollment Form printable pdf download

Illinois Premise Alert Program Enrollment Form

Stephenson County E911

320 W Exchange St, Freeport, IL 61032

Please Print Legibly

New

Change Information

Remove Information

Name: _________________________________________________ Date of Birth: _______________________

Residential address:

_______________________________________________________Apt. # ___________

City: __________________________ State: ________________ Zip: ________________

Home Phone:______________________ Work/Cell Phone________________________

Place of employment: ________________________________________________________________________

Address: ________________________________________________________________

City: __________________________ State: ________________ Zip: ________________

Educational Facility: (if applicable) _______________________________________________________________

Address: ________________________________________________________________

City: __________________________ State: ________________ Zip: ________________

Special Needs: _______________________________________________________________________________

___________________________________________________________________________________________

I understand the information given above is intended to offer guidance and provide assistance to responders in

assisting those people with special needs or disabilities in the performance of their duties. Presenting this

information will not entitle to or result in any form of preferential treatment. This information will be kept on

file for a period not to exceed two (2) years.

A notification, whether public or private, will be made prior to that 2

If the information is not confirmed at that time, the information will be removed from this

year deadline.

database. It shall be the responsibility of the undersigned to notify Stephenson County E911 in writing of any

changes to this information as soon as those changes are known. The information entered into the Premise

Alert Program (PAP) database shall remain confidential. This information will be relayed to responding public

safety personnel via two-way radio, phone, computer or any means available. The undersigned hereby verifies

the above person has a physical or mental impairment, or has or is at increased risk for a chronic physical,

developmental, behavioral, or emotional condition and who also requires health and related services of a type

or amount beyond that required by individuals generally. The undersigned is the above named individual, a

family member, friend, caregiver, or medical personnel familiar with the individual. By signing, I certify I have

read and understand this form in its entirety and hereby give permission to Stephenson County E911 to enter

this information into the Premise Alert Program (PAP) database.

Print Name: __________________________________________

Relationship: _____________________

Signed: ______________________________________________

Date: ___________________________

Illinois Premise Alert Program Enrollment Form