Illinois Premise Alert Program (PAP) Enrollment Form

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I understand the information given above is intended to offer guidance and provide assistance to responders in assisting those people with special needs or disabilities in the performance of their duties. Presenting this information will not entitle to or result in any form of preferential treatment. This information will be kept on file for a period not to exceed two (2) years. If the information is not confirmed at that time, the information will be removed from this database. It shall be the responsibility of the undersigned to notify Montgomery Police Telecommunications in writing of any changes to this information as soon as those changes are known. The information entered into the Premise Alert Program (PAP) database shall remain confidential and shall be used to provide assistance to emergency medical and police responders. This information will be relayed to responding public safety personnel via two-way radio, phone, computer or any means available. The undersigned hereby verifies the above person has a physical and/or mental impairment, or has or is at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also requires health and related services of a type or amount beyond that required by individuals generally. The undersigned is the above named individual, a family member, friend, caregiver, or medical personnel familiar with the individual. By signing, I certify I have read and understand this form in its entirety and herby give permission to Montgomery Police Telecommunications to enter this information into the Premise Alert Program (PAP) database. Further, that by signing this document, I hereby release Montgomery Police Telecommunications and any agents or assigns from any and all liability arising out of the use of this form, the information contained in this form, or the Illinois Premise Alert Program. Pursuant to Illinois law, Montgomery Police Telecommunications shall not be subject to civil liability for duties relating to the reporting of special needs individuals. Further, that no contract or legal right is created by the signing of this document.
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