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Illinois Premise Alert Program
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Special concerns or conditions
Describe in detail.
Name of Workplace or Educational Facility
Does the medication affect;
Potential to Violence
Other (Describe below)
Describe in Detail
Please indicate if the special needs person is;
Sensitive to Light
Sensitive to Touch
Subject to Seizures
Likely to Hide
Likely to Fight
Afraid of Police/Uniformed People
What actions should be avoided by officers/medics
Please list any "activations" or actions which may escalate a confrontation with the special needs person.
Which can be taken to successfully resolve a confrontation.
Guardian or Information Provider
This request was made by the below listed individual (who is also the contact person).
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
I affirm all the above is true to the best of my ability and understand that this information will be maintained for 2 years from the date of entry pursuant to Illinois Public Act 096-0788 and by volunteering to participate in the Illinois Premise Alert Program, I (or person listed) will not be afforded preferential treatment. Riverside Police will contact me at the end of 2 years to check if I wish to continue in the program.
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