Please use this form to provide information to be entered                   Harvard Fire Protection District
 pursuant to the Illinois Premise Alert Program Act (430 ILCS 132)    Po Box 263                   
into the computer aided dispatch database for the                             Harvard, Il   60033
 Harvard Fire Protection District                                                   Telephone #: (815) 943-6927

Name:___________________________________________________________    Date of Birth: _______________________

Residential address: _________________________________________________________________   Apt. # ___________

City: _____________________________________________________________State: __________ Zip: ________________

Home Phone: _______________________ Work/Cell Phone: ______________________ Other: ______________________

Place of employment: (if applicable)_______________________________________________________________________

Address: ____________________________________________________________________________________________

City: ____________________________________________________________ State: __________ Zip: ________________

Educational Facility: (if applicable) ________________________________________________________________________

Address: ____________________________________________________________________________________________

City: ____________________________________________________________ State: __________ Zip: ________________

Special Needs: _______________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

I understand the information given above is intended to offer guidance and provide assistance to responders in assisting those people 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 on file 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 _____________________________________________________ in writing of any changes to this information as soon as those changes are known. The information entered into the Premise Alert Program (PAP) database shall remain confidential. This information will be relayed to responding public safety personnel via two-way radio, phone, computer or any means available. The undersigned hereby 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. By signing, I certify I have read and understand this form in its entirety and hereby give permission to the McHenry County Emergency Telephone System Board to enter this information into the Premise Alert Program (PAP) database.

Print Name: ___________________________________________________ Relationship: __________________________

Signed: ______________________________________________________ Date: _________________________________