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Who can fill out this form?
Individuals with special needs
Parents of minor children
Guardians of minor children
Current Foster
Care Parents (child’s name isn’t required)
Those with LEGAL guardianship for another
Those with the
Power of Attorney for another
If you do not have a legal right to provide this information,
you should NOT fill out this form or provide this information
Some individuals who are identified as having
special needs are also at a higher risk for coming in contact with police or other first responders. They may wander
away from home, or have medical or emotional issues that necessitate calling for help more frequently. The Premise Alert
Form was developed to support families and first responders . The goals of this checklist are to reduce the occurrence
of unfortunate incidents and supply the police with critical information that is specific to the individual.
Filling out this form
is voluntary. You do not have to fill out this form.
The information you provide will be kept confidential and will only be used in the event that your family requires intervention.
A “premises alert” will be attached to your home address in the 911 command center so that pertinent information
will be available to the responding officer if the need arises. Situations in which this information might be used could
include, the child is lost, a child shows aggressive or dangerous behavior, a fire at your home, a medical emergency that
requires an ambulance to be dispatched...
This form is being provided as a service to
families. Not all families will feel the need to fill out this form. Families who need to call their police department
for support or intervention may find that having this form on file will give the responding officer some background information
on the individual to interact more successfully. It is intended to be a safety net for families.
If you choose to fill out this form, you may mail or hand deliver it to the police station that serves your area. If you are
unsure of which police department serves your area, contact your township or town government office and they will assist you.
If you are in an area where the state police assist your local department make a second copy for them.
Do not call 911 unless it is an emergency.
If you don’t have a current photo of your family member who is at increased risk for police or emergency encounters,
call ahead to the police department for an appointment and they will take a digital photo of him/her to attach to the form.
If you have any questions contact the department of Human Services or Aging in your county or a MH/MR
case manager, wrap-around provider or county social worker. They will be able to help you. This form must be renewed
for accuracy each year.
This form must be renewed annually in order for 911 to keep it in the system.
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