FAIRVIEW HEIGHTS POLICE

FAIRVIEW HEIGHTS POLICE

10027 BUNKUM ROAD FAIRVIEW HEIGHTS. IL . 62208 . PHONE: (618) 489-2100 FAX: (618) 489-2109 ONLINE AT: www.fairviewpd.org www.facebook.com/fairviewpd
PREMISE ALERT PROGRAM

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The Premise Alert Program is designed to assist first responders in the performance of their duties while interacting with members of the community who have special needs or disabilities. This is especially important should the person wander away from their family, caretaker, or education facility and become lost. This program is free of charge and is open to all Fairview Heights residents, caretakers of individuals with special needs, and anyone with special needs who works or attends school in Fairview Heights.

You may self-enroll in the program or have a family member or caretaker complete the enrollment. Once you have completed the form, please print it and return it, with all accompanying documents, to Premise Alert Program, Fairview Heights Police Department, 10027 Bunkum Road, Fairview Heights, Illinois 62208. You may mail the form, drop it off at the Police Department, e-mail it to hopkins@fairviewpd.org, or fax it to 618-489-2159.

Once the information is collected, it will remain on file for a period of two years. It is the responsibility of the enrolling person to notify the department of any changes, as well as any request to maintain the information beyond this period. If no request is received, the information will be removed from the database upon date expiration. The Fairview Heights Police Department may contact you periodically to update the information provided.

The information provided will be considered confidential and only be used in an emergency. The information may be relayed to responding entities via two-way radio, phone, computer, or any means available.

This section pertains to the person for whom alert is being created
Name (include nickname)
Date of Birth

MonthDayYear
Date
Gender
Preferred Pronouns
Height
Weight
Phone
Type
Home Address
Additional Description (eye color, hair color, race, clothing, etc...)
Diagnosis/Reason for Request
School Name/Location
Place of Employment
Parent/Guardian Name
Parent/Guardian E-Mail Address
Parent/Guardian Phone Numbers
Sibling Names
Do they wear/carry any tracking technology device (if so, provide details)?

YesNo
Are they verbal?

YesNo
Do they have special needs siblings?

YesNo
Are they familiar with outdoors?

YesNo
Are they familiar with traffic?

YesNo
Will they respond if their name is called?

YesNo
Have they wandered away before (If so, provide details)?

YesNo
Provide details
Are they attracted to roads/highways?

YesNo
Are they attracted to schools/playgrounds?

YesNo
Are they fascinated with vehicles?

YesNo
Are they attracted to water ?

YesNo
Do they have a favorite place to go (if so, provide details)?

YesNo
Provide details
Do you know of any specific hazards in your neighborhood (if so, provide details)?

YesNo
Explain
Do you know of any specific areas where the person would wander (if so, provide details)?

YesNo
Provide details
Do they take medication (if so, provide details)?

YesNo
Provide details
Do they become upset easily (if so, what calms them down)?

YesNo
Provide details
Do they have any specific dislikes, fears, or behavioral triggers (if so, provide details)?

YesNo
Provide details
What is their response to being touched?
How do they respond to pain?
Will they respond to a first responder (if yes, please list their response)?
Do they have a prosthesis (If yes, provide details?
Will they know their parent's/guardian's name, address, or phone number?

YesNo
Will they know their address?

YesNo
Will they know their phone number?

YesNo
How is their overall physical condition?

ExcellentGoodFairPoor
How is their overall health?

ExcellentGoodFairPoor
Do they have any physical disabilities (if yes, provide details)?

YesNo
Provide details
Please use the below space for any additional information which may assist first responders.
To ensure the highest level of care possible, we ask that you please complete the form in its entirety. Additionally, please attach a recent photo. Please understand that the photo will not be returned to you, as it will become part of the enrollee's file to be used in case of emergency.

Please acknowledge and accept that in the event of a missing person's report, the Fairview Heights Police Department may release the enrollee's name, age, physical descriptions, last known location, last known clothing, and photograph.
Signature

Clear
Date

MonthDayYear
Date
The undersigned verifies that the enrollee has a physical or mental impairment, or has or is at increased risk for a chronic physical, developmental, behavioral, or emotional condition, or who also requires health and related services of a type or amount beyond that required by individuals generally. The undersigned is the enrollee, a family member, friend, caregiver, or medical personnel familiar with the enrollee. By signing, you certify that you have read and understand this form in its entirety and hereby give permission to the Fairview Heights Police Department to enter this information into the Premise Alert Program (PAP) Database/Computer Aided Dispatch (CAD) system. No contract or legal right is created by this document, and presenting this information does not entitle or result in preferential treatment.
Printed Name
Relationship
Signature

Clear
Date

MonthDayYear
Date
Date Received

MonthDayYear
Date
Received By
Date Entered into PAP

MonthDayYear
Date
Entered By
Date Entered into ITI

MonthDayYear
Date
Entered By
Date Entered into CAD

MonthDayYear
Date
Entered By
Date of Enrollment Expiration

MonthDayYear
Date
Type a question
Should be Empty: