Illinois Premise Alert Program

2. First Name
3. Last Name
4. Nickname
6. Birth date
   Birth date
7. Gender

   1. Male
   2. Femal
8. Weight
9. Height
11. Race
12. Eye Color
13. Photo
15. Address
16. Phone
17. Other Phone
19. City
20. State
21. Zip Code
23. Email
25. Special concerns or conditions
    Describe in detail.
27. Name of Workplace or Educational Facility
28. On medication?

    1. Yes

    1. No
30. Does the medication affect;

    1. Actions
    2. Responses

    1. Senses

    1. Potential to Violence

    1. Other (Describe below)
32. Describe in Detail
34. Please indicate if the special needs person is;

    1. Sensitive to Light
    2. Sensitive to Touch
    3. Subject to Seizures

    1. Verbal Abuse
    2. Likely to Hide

    1. Likely to Fight
    2. Afraid of Police/Uniformed People

    1. Violent
    2. Other (describe)
36. Describe
38. What actions should be avoided by officers/medics
    Please list any "activations" or actions which may escalate a confrontation with the special needs person.
39. Suggestions/Techniques/Actions
    Which can be taken to successfully resolve a confrontation.
41. Guardian or Information Provider
    This request was made by the below listed individual (who is also the contact person).

    This request was made by the below listed individual (who is also the contact person).
43. First Name
44. Last Name
45. Relationship
47. Phone Number
48. Email Address
50. Address
52. City
53. State
54. Zip Code
56. 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.

    1. I agree.
58. Electronic Signature
59. Date
    Date
61. Application Type

    1. New Applicant
    2. Updated Info
    3. Renewal
62. Received by
    Received by
63. Entered into CAD by
    Entered into CAD by
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit Submit and Print

* indicates a required field