E-Gov Services Village of Winthrop Harbor

WARNING! Please do not use this form to report issues of an emergency nature or for conditions requiring an immediate response. If your issue is an emergency, please use the telephone and dial 911.

Special Needs/Elderly Contact Information

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Purpose. This form is for submitting emergency information for citizens of Winthrop Harbor with Special Needs or the Elderly that may need Police or Fire assistance. This is to allow the Police Department to respond to a missing person or found person that may have wondered from their residence with the appropriate information to assist in a timely manner. We request that this information is updated annually or when there are changes.

* Information is required.

Contact Information

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

* Medical Conditions:

* Allergies:

* Current Medications:

* Primary Physician:

* Physician Phone Number:

* EMERGENCY CONTACTS - Primary, Name

* Home Phone:

* Mobile Phone:

* Home Address:

Notes:

SECONDARY CONTACT - Name:

Home Phone:

Mobile Phone:

Address:

Notes:

TERTIARY CONTACT - Name:

Home Phone:

Mobile Phone:

Address:

Notes:

ADDITIONAL INFORMATION:

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* Information is required.

Notes:

If you send us a message, you will receive a Tracking Number allowing you to follow-up with your request, at your convenience.

Internal Use Only, Leave Blank:
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