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Resident Emergency Contact Form
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In order to better assist you in times of an emergency, the Village of Riverside is offering all residents the opportunity to provide the Fire/Police Departments with pertinent information. This program is completely voluntary. The information provided will be used for emergency purposes only.
Does someone with special needs live in the household?
Fill out an Illinois Premise Alert Form
The Illinois Premise Alert Program is a safety program that supports individuals living with disabilities, while aiding public safety personnel to better respond to their needs.
Dogs on the premise?
Where are they located?
Image of the Residence
Number of Stories
Not including basement.
Do you have a fire sprinkler system?
Do you have an exterior lock box?
Where is it located?
Lock Box Code
Any hazardous chemicals (other than normal household supplies) stored in your home?
Please list them and the location
Emergency Contact 1 Name
Emergency Contact 2 Name
Emergency Contact 3 Name
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.
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