Morton Grove Premise Alert Program Notification Form

Morton Grove

Premise Alert Program Notification Form

The Illinois Premise Alert Program (Public Act 96-0788) provides for Public Safety Agencies in the State of Illinois to allow people with disabilities, special needs, or both to provide information to police, fire and EMS personnel to be kept in a database. The information provided can be used to offer guidance and assistance to public safety workers in responding to and assisting those persons with disabilities or special needs. Families, caregivers, or the person with a disability or special needs may provide this information.

The below information provided by you will be kept confidential and used only to provide Police, Fire and EMS personnel with the information needed to deal with situations or emergencies involving a Special Needs person.

The notification expires 2 (two) years after the date it was submitted. Information must be updated every two years, or whenever the information changes. You may update or renew it at any time by re-filing this form.

The data is provided by the individual or other person in order to provide responding Police, Fire and EMS personnel additional information to use while performing their duties. The information will be entered into databases maintained by the Police and Fire Departments and may be shared with other police, fire or EMS agencies as needed to provide services to the individual.

By submitting this form, I am representing that I am authorized to provide this information, and I am giving permission for this information to be entered into databases for use by the Police and Fire Department, and other emergency services agencies as needed. I understand that the information provided will not result in any type of preferential treatment for anyone, and that neither the Village of Glenview, its Police and Fire Departments, nor any other emergency services agencies can be held liable for duties relating to reporting this information.

I also understand that if any of the information changes I am responsible for notifying the Glenview Public Safety Dispatch Center by filing an amended request form. The information will self expire 2 (two) years from the date received by the Dispatch Center, and I am responsible for renewing the form if I want the information kept in the Police and Fire Databases.

Special Needs / Disability Information:*

NewUpdateRenewal

Name*

First NameLast Name

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

.

Cell Phone

Employer

Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Work Phone

Other Phone

Date of Birth*

Sex*

MF

Height*

Weight*

Eyes*

Hair*

Please advise the nature of the special needs or disability for this individual: *

Please advise what type of precautions Emergency Services personnel should be aware of*

Contact Email*

This information is begin provided by*

The individual named aboveThe individual information provided below

Name

First NameLast Name

Relationship to the Special Needs Person

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

.

Alternate Phone

.

Special Needs / Disability Information

Information Provider / Contact persons