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Address:_________________________________________________________________________________
_________________________________________________________________________________________

County: ____________________________Township/Borough/Municipality:________________________

Individual’s Current Physical Description:

___Male     ___Female
Attach recent
Height:             Weight:                                         photo here
____________     ____________

Eye color:       Hair color:
____________       ____________

Scars or other identifying marks:___________________________________________________
_______________________________________________________________________________________

Relevant Medical Conditions:
___Blind     ___Deaf     ___ Non-Verbal     ___Physical Disability    ___Developmental Disability

___Mental Retardation     ___Autism       ___Mental Health Challenges     ___Diabetes

___ Prone to Seizures     ___Alzheimer’s Disease     ___Dementia     ___ Acquired Brain Injury

___Other Relevant Medical Conditions, area for further explanation: _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
HIV/AIDS IS NOT CONSIDERED A RELEVANT MEDICAL CONDITION FOR PURPOSES OF THIS FORM AND THE PREMISE ALERT SYSTEM AND PROGRAM. UNDER NO CIRCUMSTANCES SHOULD INFORMATION RELATED TO AN INDIVIDUALS   HIV/AIDS STATUS BE DISCLOSED ON THIS FORM BY ANYONE. * The name of the individual described on this form may be left off for reasons of privacy or confidentiality. However, in situations involving group homes, foster-care homes, or supportive living arrangements, one may simply enter the first name of the Individual to protect confidentiality. (That will not affect the acceptance or further processing of the information on this form.)

Prescription Medications needed:
_______________________________________________________________________________________
_______________________________________________________________________________________
Sensory or dietary issues, if any:
_______________________________________________________________________________________
_______________________________________________________________________________________

Additional information First Responders may need:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Does the Individual live alone? ___________

Is he/she likely to wander off? _____________________

Location of bedroom or likely place to find them in the household/residence at night:

_______________________________________________________________________________________

EMERGENCY CONTACT INFORMATION

Name of Emergency Contact (Parents/Guardians, Head of Household/Residence, or Care Providers):
_______________________________________________________________________________________

Emergency Contact’s Address:
_______________________________________________________________________________________
_______________________________________________________________________________________

County: _______________________Township/Borough/Municipality: ___________________________

Emergency Contact’s Phone Numbers:

Home: _______________________________     Work: ______________________

Cell Phone: _______________________________     Pager: _____________________________

TTD/TTY: __________________________________________

Name of Alternative Emergency Contact:   _________________________________________

Home: ___________________________      Work: ____________________________

Cell Phone: _______________________________     Pager: _____________________________

TTD/TTY: __________________________________________

INFORMATION SPECIFIC TO THE INDIVIDUAL

Favorite attractions or locations where the individual may be found:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Atypical behaviors or characteristics of the Individual that may attract the attention of Responders:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Individual’s favorite toys, objects, discussion topics, likes, or dislikes:
_______________________________________________________________________________________
_______________________________________________________________________________________

Method of Preferred Communication. (If nonverbal: Sign language, picture boards, written words, etc.):

_________________________________________________________________________________________

Identification Information. ( i.e. Does the individual carry or wear jewelry, tags, ID card, medical alert bracelets, etc.?):

__________________________________________________________________________________________

IMPORTANT: Please review the following before completing, signing, and/or submitting this Premise Alert Form
If you choose to respond, the information may be submitted and added to the local, city, county, or state police dispatch systems for Emergency Operations.

Responding to this form is voluntary.   This form may be filled out by the individual living with the specified health challenge or disability, their parent/guardian (in the case of a minor), assigned caregiver, or recognized representative. If an individual or their representative chooses to use this form, they must provide their signature on the last page. (The signature of the person completing this form is required to process the information contained on the form.) In addition, this information may be removed from files periodically. Therefore, it is recommended that individuals or their representatives update and submit this form every year to ensure that files are kept updated and accurate.
Please be aware:   The information provided on this form may assist police, fire, or emergency response personnel, when they are responding to an emergency or other call from your home, for purposes of identifying and/or assisting you or another Individual in your household who is living with a disability or health challenge.

Required Acknowledgment and Signature/s of Individual/s Completing and Submitting this Premise Alert Form:

By completing the Premise Alert Form, I acknowledge that the information provided herein is accurate and was submitted voluntarily for the sole purpose of assisting Police, Fire, and Emergency Response Departments in more effectively responding to a potential emergency in or near my household. I, therefore, authorize the use of this information for those purposes and to the maximum extent that I am empowered to do so, waive any claim in law and/or equity against any of the above mentioned responder(s) which I, or ____________________ (the individual’s name), or any of our representatives, descendents, or successors, might otherwise have arising from or related to the use or existence of the information provided herein. I understand that providing this information on the Premise Alert Form does not entitle me or anyone in my household, including ____________________ (the individual’s name), to preferential treatment, including a more timely response by emergency response personnel. I also understand and agree that this information may be considered, only if the circumstances and exigencies confronting the police or other emergency responders permit. I also understand that if the information provided on the Premise Alert Form is considered, it may be considered along with all other relevant sources of information, and subject to proper police and emergency response procedures, when police, fire department or other emergency response personnel are responding to the residence of the individual for whom this form is being completed. Completion and submission of this form is simply an attempt to provide emergency response personnel with information that may be helpful when providing services to residents or occupants of my home, in or near my household.
I hereby verify that the representations made herein are true and correct to the best of my knowledge, information and belief. I acknowledge that written false statements made herein are punishable pursuant to Title 18 Pa.C.S. §4904(b) as a misdemeanor of the third degree.   __________

If you need assistance with this form due to a language barrier contact SPEAK Unlimited Inc at srz@dol.net or P.O. Box 98, Landenberg PA 19350