Resident Name:

Telephone Number:

Company Name:

Street Address:

City:

State:

Zip:

Township:

In the event that you dial 911 form your home/business, your call is answered by a 911 dispatcher; a screen opens and displays information pertaining only to your telephone number (this does not apply to cellular telephones). It automatically gives the telephone number, address, and the name of the person the telephone is billed to. There is an area for special information that may be helpful for the police, fire, or ambulance when responding to your emergency. Complete the form below so any special conditions or instructions you want provided to emergency personnel is available to the dispatcher. All information is provided directly to the dispatcher when you dial 911 and is held in the strictest confidence.

Information from this form is submitted to the Sheriff's Department.

Disability:

Location in Residence:

Emergency Contact Name and Number:

Hearing Impaired Phone on site:

Direct Dial Number:

Known Allergies to Medications:

Necessary Medical Equipment on site:

Oxygen in use:

Type:

Location:

Any other information that would permit ambulance, police and fire to more efficiently assist you in an emergency: