Premise Alert Enrollment Form

Illinois Premise Alert Program (PAP) Enrollment Form

The Illinois Premise Alert Program (Public Act 96‐0788) provides for Public Safety Agencies in the State of Illinois to save pertinent information, which can be used by police, fire and EMS personnel in the event of a 911 emergency. The information provided, if approved by the Emergency Telephone System Board (ETSB), is kept confidential and stored in a database, which will alert first responders should an emergency occur at the listed address.

The notifications expire two years after the submission date. Applicants will be responsible for filing a renewal form if they wish to continue the service.

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Form Type *

New

Change of Information

Renewal

Applicant Name *

Date of Birth

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Phone Number *

Street Address

Address for which you are applying for: (include City) *

Land Line Number

Knox Box on Premise *

Yes

Emergency Contact Name *

Emergency Contact Number *

Please advise nature of special needs for this individual: *

Please advise what type of precautions Emergency Service Personnel should be aware of: *

I understand that the information given above is intended to offer guidance and provide assistance to responders in the event of an emergency. Presenting this information will not entitle or result in preferential treatment. This information will be kept confidentially for a period of two years. Notification of termination, whether public or private, will be made prior to the two‐year period. A renewal form will need to be submitted or the information will be removed from the database. It is the responsibility of the undersigned to notify the McHenry Township Fire Protection District, in writing, of any change of information as soon as those changes occur. By signing, I certify that I am the above named individual, family member or healthcare provider with rights to enter the above information on behalf of the individual. I have read and understand this form in its entirety and give permission to the McHenry Township Fire Protection District to forward the information to the Premise Alert Program (PAP) database.

Your Name *

Relationship *

Date

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Premise Alert Enrollment Form

Illinois Premise Alert Program (PAP) Enrollment Form

Contact Information