Illinois Premise Alert Program Act

Emergency Contact Home Phone  
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 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 will be the responsibility of the undersigned to notify Milan Police Department 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. As provided by Public Act 96-788, 430 ILCS 132/1 et seq, this informatjion 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 Milan Police Department to enter this information into the Premise Alert Program (PAP) database.
Please return completed form to Milan Police Department, 504 E 1st Street, Milan, IL 61264