The Illinois Premise Alert Program (Public Act 96-0788) provides for Public Safety Agencies in the State of Illinois to allow individuals with special needs to share information with police, fire, and EMS personnel that is maintained in a database.  The information is utilized when responders are contacted to handle a situation involving a special needs individual.

Information provided by you is kept confidential and is used to provide Sheriff’s Deputies, Fire, and/or EMS personnel with the information needed to deal with situations or emergencies involving a special needs individual.  The notification expires two (2) years after the date it was submitted.  Submit completed forms to the Kane County Sheriff’s Office, 37W755 IL Route 38, Attn: Training Officer, St. Charles, Illinois 60175.

Submittal of this form does not result in preferential treatment to the individual.  By registering for and participating in this program, you will be waiving your rights to all claims and you will hold harmless and defend the Kane County Sheriff’s Office for any claims arising out of participation in said Program.  I also understand that if any information changes, I must notify the Kane County Sheriff’s Office by filing an amended form.

Special Needs Information - Please list the nature of the special needs for above.

Guardian or Information Provider: