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2. Status of Request*

   1. New
   2. Removal
   3. Change of Information
   4. Renewal
3. E-Mail Address
7. Last Name*
8. First Name*
10. Gender*
    -- Select One --MaleFemale
11. Race*
    -- Select One --CaucasianHispanicAfrican AmericanAsianPacific IslanderOther
13. Date of Birth*
    Date of Birth
14. Telephone Number*
15. Alt. Telephone #
17. Address1*
19. Address2
21. City*
22. State
23. Zip
27. Place of Employment or School Attending
29. Address1
31. Address2
33. City
34. State
35. Zip
39. Please List Any Special Needs
41. I understand the information given above is intended to offer guidance and provide assistance to responders in aiding those individuals with special needs or disabilities in the performance of their duties. Presenting this information will not entitle me to or result in any form of preferential treatment. This information will be kept confidential for a period not to exceed two (2) years. After two (2) years, a renewal must be completed to maintain this information. It shall be the responsibility of the undersigned to notify the Waukegan Police Department of any changes to this information as soon as those changes are known. This information may be relayed to responding public safety personnel via two-way radio, telephone, computer, or other method available. The undersigned hereby verifies the above person has a physical or mental impairment, or has an increased risk for a chronic physical, developmental, behavioral, or emotional condition who also requires health and related services beyond those required by individuals generally. The undersigned is the above named individual, a family member, friend, caregiver, or medical professional familiar with the individual and his/her needs. By signing, I certify I have read and understand this form in its entirety and hereby give permission to the Waukegan Police Department to enter this information into the Premise Alert Program database.
43. By entering the information below, I am signing this document and certifying that the information contained herein is accurate and I also understand the terms of the Premise Alert Program
45. First Name*
46. Last Name*
48. Relationship to Requestor*
49. Date of Request*
    Date of Request
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51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit Submit and Print

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