Skip to Main Content
Loading
Loading
Government
Community
Business in Riverside
How Do I...
Search
Home
Form Center
Form Center
Search Forms:
Search Forms
Select a Category
All Categories
Administration
Boards & Commissions
Community Development
Finance
Green Initiatives
job application
Parks and Recreation
Police
Public Works
Your Government
By
signing in or creating an account
, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
Resident Emergency Contact Form
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
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.
Resident Information
Name
Phone Number
Cell Number
Work Number
Address
Email Address
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.
Pet Information
Dogs on the premise?
Yes
No
Breed(s)
Name(s)
Exotic Pets?
Yes
No
Type
Where are they located?
Home Information
Image of the Residence
Number of Stories
Not including basement.
Basement?
Yes
No
Attic?
Yes
No
Do you have a fire sprinkler system?
Yes
No
Do you have an exterior lock box?
Yes
No
Where is it located?
Lock Box Code
Any hazardous chemicals (other than normal household supplies) stored in your home?
Yes
No
Please list them and the location
Emergency Contact 1 Name
Phone Number
Email
Relationship
Emergency Contact 2 Name
Phone Number
Emergency Contact 3 Name
Phone Number
Additional Comments
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 agree.
Electronic Signature
Leave This Blank:
Submit
Submit and Print
* indicates a required field
Pay
Report a Concern
Notify Me®
Public Notices
Forms
Agendas & Minutes
Facebook
Twitter
Instagram
YouTube
LinkedIn
Newsletter
Arrow Left
Arrow Right
[]
Slideshow Left Arrow
Slideshow Right Arrow