Premise Alert Program Notification Form
The Illinois Premise Alert Program (Public Act 96 - 0788) provides for public safety agencies in the State of Illinois to allow people with special needs to provide information to police, fire and EMS personnel to be kept in a database. The information can then be provided to responders dealing with situations involving the special needs individuals. The below information provided by you will be kept confidential and used only to provide police, fire and EMS personnel with the information needed to deal with situations or emergencies involving a special needs person.
The notification expires two (2) years after the date it was submitted. You may update or renew it at any time by filing a new form.
Forms may be submitted below or can be mailed to:
Rosemont Public Safety Department
9501 West Divine Ave.
Rosemont, Illinois 60018
The data is provided by the individual or other person in order to provide responding police, fire or EMS personnel information to provide emergency services. The information will be entered into a database maintained by the Public Safety Department and may be shared with other police, fire or EMS agencies as needed to provide services to the individual.
The individuals must understand that the information provided here will not result in any type of preferential treatment to the individual and that the Village of Rosemont, it's Public Safety Department or any other responding agencies will not be held liable for duties relating to the reporting of special needs individuals.
I also understand that if any of the above information changes I must notify the Rosemont Public Safety Department by filing an amended request form. The information will self-expire in two (2) years from the date received by the Public Safety Department and I must renew the form if I want the information kept in the Public Safety database
Information Provider / Contact Person
This information is being provided by:
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