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Illinois Premise Alert Program
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First Name
Last Name
Nickname
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Birth date
Gender
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Femal
Weight
Height
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Photo
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Phone
Other Phone
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State
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Special concerns or conditions
Describe in detail.
Name of Workplace or Educational Facility
On medication?
Yes
No
Does the medication affect;
Actions
Responses
Senses
Potential to Violence
Other (Describe below)
Describe in Detail
Please indicate if the special needs person is;
Sensitive to Light
Sensitive to Touch
Subject to Seizures
Verbal Abuse
Likely to Hide
Likely to Fight
Afraid of Police/Uniformed People
Violent
Other (describe)
Describe
What actions should be avoided by officers/medics
Please list any "activations" or actions which may escalate a confrontation with the special needs person.
Suggestions/Techniques/Actions
Which can be taken to successfully resolve a confrontation.
Guardian or Information Provider
This request was made by the below listed individual (who is also the contact person).
First Name
Last Name
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Address
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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.
I agree.
Electronic Signature
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