Resident Emergency Contact Form

2. In order to better assist you in times of an emergency, the Village of Riverside is offering all residents the opportunity to provide the Fire/Police Departments with pertinent information. This program is completely voluntary. The information provided will be used for emergency purposes only.
4. Resident Information
6. Name
7. Phone Number
9. Cell Number
10. Work Number
12. Address
13. Email Address
15. Does someone with special needs live in the household?
    Fill out an Illinois Premise Alert Form

    The Illinois Premise Alert Program is a safety program that supports individuals living with disabilities, while aiding public safety personnel to better respond to their needs.
19. Pet Information
21. Dogs on the premise?

    1. Yes
    2. No
22. Breed(s)
23. Name(s)
25. Exotic Pets?

    1. Yes
    2. No
26. Type
27. Where are they located?
31. Home Information
33. Image of the Residence
34. Number of Stories
    Not including basement.
36. Basement?

    1. Yes
    2. No
37. Attic?

    1. Yes
    2. No
38. Do you have a fire sprinkler system?

    1. Yes
    2. No
40. Do you have an exterior lock box?

    1. Yes
    2. No
41. Where is it located?
42. Lock Box Code
44. Any hazardous chemicals (other than normal household supplies) stored in your home?

    1. Yes
    2. No
45. Please list them and the location
49. Emergency Contact 1 Name
50. Phone Number
52. Email
53. Relationship
57. Emergency Contact 2 Name
58. Phone Number
62. Emergency Contact 3 Name
63. Phone Number
67. Additional Comments
69. 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.

    1. I agree.
71. Electronic Signature
Leave This Blank:


73. Submit Submit and Print

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