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Premise Alert Enrollment Form

Premise Alert Program

 

Status of Requestor

New

Change Information

Remove Information

Renewal

Name

Date of Birth

Gender

Male

Female

Height

Weight

Hair Color

Eye Color

Residential Address (Street, Apt#, City, State, Zip Code)

Home Telephone

Cellular Telephone

Place of Employment (Address, City, State, Zip Code)

Telephone Number

School Attending (Address, City, State, Zip Code)

Telephone Number

If applicable, please upload a photograph

 

Please specify any additional special needs

By entering my name, 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 year deadline. If the information is not confirmed at that time, the information will be removed from this database. It shall be the responsibility of the undersigned to notify the Highland Park Police Department 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 the Highland Park Police Department to enter this information into the Premise Alert Program (PAP) database.

Name of Person Submitting Form

Relationship

Date

Emergency Contact Telephone Number