Premise Alert Program

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Premise Alert Notification Form

Premise Alert Program

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Premise Alert Notification Form

 

Please correct the field(s) marked in red below:

The Illinois Premise Alert Program (Public Act 96-0788) provides for Public Safety Agencies in the State of Illinois to allow people with special needs to provide information to Police, Fire, and EMS personnel to be kept in a database.  The information can then be provided to responders dealing with situations involving the Special Needs individuals.  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.  You may update or renew the Premise Alert Notification at any time by filling out the form. 

 

Individuals must understand that the information provided here will not result in any type of preferential treatment to the individual.  The Village of Hoffman Estates, its Police and Fire Departments, nor any other responding agencies will not be held liable for duties relating to the reporting of special needs individuals. 

 

If you understand and agree to these terms, please submit the following information online.  A printable form is also available here and can be completed and returned to:

Hoffman Estates Police Department
Staff Services Sergeant
411 West Higgins Road
Hoffman Estates, IL 60169

PREMISE ALERT PROGRAM NOTIFICATION:
PREMISE ALERT PROGRAM NOTIFICATION:

SPECIAL NEEDS PERSON INFORMATION:

LAST NAME:

 *
FIRST NAME:
 *
ADDRESS:
 *

CITY:

 *
STATE:
 *
ZIP CODE:
 *
HOME PHONE:
CELL PHONE:
DATE OF BIRTH:
 *
GENDER:
GENDER:
HEIGHT:

WEIGHT:

EYE COLOR:

HAIR COLOR:

SPECIAL NEEDS INFORMATION: Please advise nature of Special Needs for this individual:

 *
Please advise what type of precautions Emergency Service Personnel should be aware of:
 *

CONTACT PERSON / INFORMATION PROVIDER:

LAST NAME:

 *
FIRST NAME:
 *
RELATIONSHIP TO THE SPECIAL NEEDS PERSON:
 *
ADDRESS:
 *
CITY:
 *
STATE:
 *
ZIPCODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
IN CASE OF EMERGENCY CONTACT:
IN CASE OF EMERGENCY CONTACT:
  1. To receive a copy of your submission, please fill out your email address below and submit.