E-Gov Services Village of Vernon Hills

WARNING! Please do not use this form to report issues or conditions requiring an immediate response. If your issue is an emergency or you need an immediate response, please call 911. For other police issues, please call our non-emergency number at 847-362-4449.

Premise Alert Program Entry Request

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Purpose. This form is used to communicate with Village personnel to request services or miscellaneous information related to the Police Department. The Illinois Premise Alert Program (PAP) provides for Public Safety Agencies in the State of Illinois to allow people with disabilities, special needs, or both to provide information to police, fire, and EMS personnel to be kept in a database. The information provided can be used to offer guidance and assistance to public safety workers in responding to and assisting those people with disabilities or special needs. Families, caregivers, or a person with a disability or special needs may provide this information. The information provided will be kept confidential and used only to provide first responders with the information needed to deal with situations or emergencies involving a special needs person. An entry request form expires two (2) years after the date it is submitted. Information must be updated every two years, or whenever the information changes. You may update or renew it at any time by re-filing the form with the Village of Vernon Hills Police Department. If you have any questions, please call the Vernon Hills Police Department Crime Prevention Unit at (847) 247-4889.

* Information is required.

Contact Information

* First Name:
* Last Name:
* Email:
* Daytime Phone:	() –
* Address:
* City:
* State:
* ZIP:

* For the above listed contact who is responsible for completing this form, please list your RELATIONSHIP to the individual with special needs/disability:

* FULL NAME of individual with special needs/disability:

* HOME ADDRESS of individual with special needs/disability (*must be within the corporate limits of Vernon Hills):

* PHONE NUMBER of individual with special needs/disability:

* DATE OF BIRTH of individual with special needs/disability:

* GENDER of individual with special needs/disability:

* RACE of individual with special needs/disability:

* HEIGHT AND WEIGHT of individual with special needs/disability: If desired, a photo of the individual can be uploaded under the Attach a Picture or File section below.

* EYE COLOR of individual with special needs/disability:

* HAIR COLOR of individual with special needs/disability:

* NAME OF EMPLOYER OR SCHOOL for the individual with special needs/disability:

* EMPLOYER/SCHOOL ADDRESS for the individual with special needs/disability:

* Nature of Disability or Special Needs of named individual:

* Advise what type of precautions first responders should be aware of:

* Is there a garage or door code first responders can use to gain access? If so, please list.

Attach a Picture or File (max size: 30MB):

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* Information is required.

DISCLAIMER:

By submitting this form, you are representing that you are authorized to provide this information, and give permission for this information to be entered into databases for use by the Police and Fire Departments, and other emergency services agencies as needed. You understand that the information provided will not result in any type of preferential treatment for anyone, and that neither the Village of Vernon Hills, its Police Department, nor any other emergency services agencies can be held liable for duties relating to reporting this information. You also understand that if any of the information changes, you are responsible for notifying the Vernon Hills Police Department by filing another form. The information will self-expire two (2) years from the date received by the Village, and you are responsible for refiling if you want the information kept in the Police Database.

NOTES:

Upon submitting a request, you will receive a tracking number which may be used to follow up with your request at a later date. Please note that requests submitted through this portal are typically resolved via e-mail, unless otherwise requested.

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