Fillable - Premise Alert Program Registration Form 11-2020

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- Premise Alert Program Registration Form 11-2020

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LivingstonCountyPremiseAlertProgram
Registration Agreement
The Premise Alert Program (PAP) exists to assist emergency responders with information critical in
helping provide the appropriate response and services. It is completely voluntary. Please identify the
appropriate choice:
☐ Alzheimer’s/Dementia Mental Illness
☐ Autism ☐ Mood Disorder
☐ Down’s Syndrome ☐ Psychotic Disorder
☐ Deaf/Hard of Hearing ☐ Impulse Disorder
☐ Vision Impaired ☐ Anxiety Disorder
☐ Physical Disability ☐ Childhood Disorder
☐ Developmental Disability ☐ Other
☐ Communication Disorder
☐ Other Disorder
Other Information you feel responders should
know:____________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Date of Registration:
Registrant
Name:
(Last) (First) (MI)
Date of Birth:
Address:
(Signature)
If you are the parent or court appointed legal guardian of the person being registered, please complete
the following.
_________________________ ____________________________
Printed (Full Legal Name) Signature
I am the ☐ Parent of the registrant
☐ Legal guardian of the registrant
* By registering into the Premise Alert Program, I also agree to
the terms/conditions (on back):
11/05/2020
SendCompletedregistrationformsto:
DropOff:atyourlocalPoliceDept.
Mailto:VCOM,844W.LincolnSte.B,Pontiac,IL
61764or
Emailto:rwittenberg@livingstoncountyil.govor
FAXto815‐844‐7399
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Livingston County Premise Alert Program Terms and Conditions
By registering for this program, I agree to the following terms/conditions.
1. I understand the Livingston County Premise Alert Program is authorized by 430 ILCS 132/1
et seq. and all participants are entitled to the full protections under the statute.
2. I authorize the application information to be entered in the Livingston County Law
Enforcement Premise Alert databases.
3. I understand that providing this information is voluntary on my part.
4. I understand the, Chatsworth, Dwight, Fairbury, Pontiac, and Streator City Police Agencies,
and the Livingston County Sheriff, and VCOM 911 intend to use the information to assist
their employees and officers in responding to police calls for service.
5. I understand providing this information does not obligate the Chatsworth, Dwight, Fairbury,
Pontiac, Streator City Police Agencies, the Livingston County Sheriff or VCOM 911, its
agents, employees and officers in any manner.
6. I hereby release and waive any claim that I may have or that may arise against the
Chatsworth, Dwight, Fairbury Pontiac, Streator City Police Agencies or the Livingston
County Sheriff, VCOM 911, their officers, employees or agents as a result of the use or
further transmission of this information, or the failure to provide this information, or the
failure to act in accordance with this information. I further agree to hold the City of
Chatsworth, Dwight, Fairbury, Pontiac, Streator City Police, Livingston County Sheriff, and
VCOM 911, their officers, employees or agents harmless from any damages caused as a
result of the use or failure to use this information.
7. I understand that I may have this information removed from the database any time by
submitting a request in writing.
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- Premise Alert Program Registration Form 11-2020

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Completed 21 January 2021

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