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2. To provide information to public safety agencies related to an individual's disability, medical issue, mobility, or other condition of which emergency responders should be aware. This does not take the place of an individual's responsibility to plan and prepare for transportation and/or sheltering in the event of an emergency. All information provided will remain completely confidential and will be used only by authorized personnel to assist in an emergency.
4. Personal Information
6. First Name*
7. Last Name*
8. MI
10. Address 1*
12. Building/Apt/Room #
13. Floor #
14. Elevator?

    1. Yes
    2. No
15. Ramp?

    1. Yes
    2. No
17. Name of Housing Complex, Mobile Home Park, Apartment Building, etc
19. City*
20. State*
21. Zip Code*
23. Primary Phone*
24. Secondary Phone/TDD
26. Email
30. Emergency Contacts
    Must provide at least one phone number.
32. Person 1*
33. City/State
34. Primary Phone Number*
35. Secondary Phone Number
37. Person 2
38. City/State
39. Primary Phone Number
40. Secondary Phone Number
44. Special Need Details - Check all that apply to applicant's condition.
46. Mobility

    1. Walks by self

    1. Walks with assistance (cane, walker)

    1. Wheelchair

    1. Bedridden
48. If bedridden, may the applicant be moved by wheelchair?

    1. Yes
    2. No
52. Communication

    1. Speech impaired

    1. TDD

    1. ASL
54. Other language spoken (please describe)
55. Other communication difficulties (please describe)
59. Life-Sustaining Medical Equipment

    1. Oxygen in use
    2. IV Therapy

    1. Respirator/Ventilator
    2. Suction machine

    1. Nebulizer
61. Other (please explain)
65. Other Needs

    1. Hearing impaired
    2. Sight impaired
    3. Anxiety/depression

    1. Service Animal
    2. Memory impaired

    1. Catheter or Drain
    2. Weight > 300 lbs
67. Allergies (please explain)
68. Mental Health impaired (please explain)
70. Autism Spectrum Disorder (please explain)
74. Emergency Alert / Medical Alert / Life Call Device
76. Device Type
77. Alarm Company
78. Phone Number
82. Home Health Care Agency
84. Agency Name
85. Point of Contact
86. Phone Number
90. Authorization*

    I understand this information will be utilized to plan appropriate care and treatment during an emergency. I understand that only those persons who have a need to know this information will have access to it. I understand that it is my responsibility to keep the provided information current. I understand I am responsible for all expenses incurred in association with medical evaluation and special sheltering in a hospital or nursing facility. I accept the conditions as specified and grant permission for Danville Fire Department to record this information in the Computer Aided Dispatch system for reference and to release this information to emergency response agencies via two-way radio in the event of an emergency.

    1. I understand
92. Electronic Signature*
    Please type full name.
93. Date*
    Date
Leave This Blank:


95. 1. Receive an email copy of this form.
96. Email address

    This field is not part of the form submission.

97. Submit

* indicates a required field