Fillable City of ILLINOIS PREMISE ALERT PROGRAM The Illinois (City of Woodstock)

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City of ILLINOIS PREMISE ALERT PROGRAM The Illinois (City of Woodstock)

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BROWSE CITY OF WOODSTOCK (IL) FORMS

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Woodstock is proud to have been recognized as a 2007 Distinctive Destination
by the National Trust for Historic Preservation
City of
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p h o n e 8 1 5 . 3 38 . 6 7 8 7
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p o l i ced ept@ wood s t o c k i l . g o v
ww w. woodsto c k i l . g o v
ILLINOIS PREMISE ALERT PROGRAM
The Illinois Premise Alert Program (Public Act 96-0788) allows people with special needs to
provide information to police, fire, and EMS first responders to be stored in a database for use in
an emergency situation. This information can then provide valuable guidance and direction to the
first responders which will assist in meeting the needs of these individuals.
The provided information will be kept confidential and will be used only to provide first
responders with the information needed to effectively deal with situations or emergencies
involving a special needs person. The information will expire two (2) years after the date
submitted and will no longer be maintained in the database thereafter unless such information is
renewed by the submitting party.
Participation in the program will not result in any type of preferential treatment to the special
needs or disabled individual. Furthermore, the act provides that the City of Woodstock, its Police
Department, and any other responding agency will not be held liable for duties relating to the
reporting of special needs or disabled individuals.
The act defines;
“Special Needs Individuals” as; “those individuals who have, or are at increased risk for, a
chronic physical, developmental, behavioral, or emotional condition and who also requires
health and related services of a type or amount beyond that required by individuals generally.”
Some examples would be, but are not limited to, deafness, blindness, autism, mobility issues,
inability to communicate, special medical needs, or any condition that may affect the needs of
the individual with regards to interaction with first responders.
“Disability” as; “means an individual’s physical or mental impairment that substantially
limits one or more of the major life activities; a record of such impairment; or when the
individual is regarded as having such an impairment.”
To participate in the program an individual, parent, guardian, family member, or caregiver must
complete a Woodstock Police Department Premise Alert Program Enrollment Form. Once
completed the form must be returned to the Woodstock Police Department, 656 Lake Avenue,
Woodstock, Illinois, 60098. Forms are available at the Police Department or here online.
Woodstock Police Department
656 Lake Ave., Woodstock, IL 60098
815-338-2131
Premise Alert Program Enrollment Form
The information provided by you below will be kept confidential and used only to provide emergency personnel with
the information needed to deal with situations or emergencies involving a special needs or disabled individual. The
information may be updated or renewed at any time by completing a new form. The City of Woodstock shall not be
subject to civil liabilities for duties relating to the reporting of special needs or disabled individuals and the following
information will not result in any type of preferential treatment to the individual. This notification expires two (2)
years after the date submitted.
New Update/Change Renewal Remove
Name: Date of Birth:
Residential Address: Apt. #
City: State: Illinois Zip:
Home Phone: Cell Phone: Other:
Place of Employment (if applicable):
Address: Work Phone:
City: State: Zip:
Educational Facility (if applicable):
Address: Phone:
City: State: Zip:
Special Needs:
I understand the information given above is intended to offer guidance and provide assistance to responders in assisting those individuals with special needs or disabilities in
the performance of their duties. Presenting this information will not entitle to or result in any form of preferential treatment. This information will be kept confidential for a period
not to exceed two (2) years. A notification, whether public or private, will be made prior to that 2 year deadline. If the information is not confirmed at that time, the information
will be removed from this database. It shall be the responsibility of the undersigned to notify the Woodstock Police Department in writing of any changes to this information as
soon as those changes are known. This information will be relayed to responding public safety personnel via two-way radio, phone, computer or any means available. The
undersigned herby verifies the above person has a physical or mental impairment, or has or is at increased risk for a chronic physical, developmental, behavioral, or emotional
condition and who also requires health and related services of a type or amount beyond that required by individuals generally. The undersigned is the above named individual,
a family member, friend, caregiver, or medical personnel familiar with the individual and their needs. By signing, I certify I have read and understand this form in its entirety and
hereby give permission to the Woodstock Police Department to enter this information into the Premise Alert Program (PAP) database.
Print Name: Relationship:
Signed: Date:
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City of ILLINOIS PREMISE ALERT PROGRAM The Illinois (City of Woodstock)

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Completed 17 July 2020

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