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Illinois Premise Alert Program

  1. Gender

  2. Describe in detail.

  3. On medication?

  4. Does the medication affect;

  5. Please indicate if the special needs person is;

  6. Please list any "activations" or actions which may escalate a confrontation with the special needs person.

  7. Which can be taken to successfully resolve a confrontation.

  8. This request was made by the below listed individual (who is also the contact person).

  9. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    I affirm all the above is true to the best of my ability and understand that this information will be maintained for 2 years from the date of entry pursuant to Illinois Public Act 096-0788 and by volunteering to participate in the Illinois Premise Alert Program, I (or person listed) will not be afforded preferential treatment. Riverside Police will contact me at the end of 2 years to check if I wish to continue in the program.

  10. Leave This Blank:

  11. This field is not part of the form submission.