_____________________________________                                                        
                                                             *Last Name, First Name of Individual     

                                                            _____________________________________                                                                     Date Form was Submitted

PREMISE ALERT REQUEST FORM
PERSON SPECIFIC INFORMATION FOR FIRST RESPONDERS

Individual’s Name__________________________________________________________________________
Date of Birth______________________________________________________________________________
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
__________________________________________________            
__________________________________________________________________
Name/ Relationship                                                                                                                       Date   ________________________________________________________________________________________            
 Name/ Relationship                                                                                                                   Date    

OFFICIAL USE ONLY                                                                   
                                                                                                             Purge Date___________________
Police Intake Signature/Date__________________________________

Dispatch Intake Signature/Date_______________________________
This form is compatible with all Pennsylvania Emergency Dispatch Systems.                                                                       3/08

This form is a collaboration between Chief Kevin McCarthy, Susan F. Rzucidlo, The Philadelphia Police Department, other Law Enforcement entities, disability advocates, parent volunteers, educators, State & County Officials and other interested parties. It is owned by SPEAK Unlimited Inc. and is protected by copyright laws.  PERMISSION: You are permitted and encouraged to  reproduce and distribute this material in hardcopy or electronic form provided that you do NOT alter the wording in any way, you do not charge a fee beyond the cost of reproduction, you give credit to the original authors, and receive written permission and approval from Chief Kevin McCarthy or Susan F. Rzucidlo if alterations or changes are being recommended for incorporation. More  information on this program and additional resources can be found at www.papremisealert.com  or  contact srz@dol.net       © 04-08.