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