Salem, IL · Marion County
Premise Alert Program Enrollment Form
The Premise Alert Program Enrollment Form lets an individual or someone familiar with them provide Salem Police with information about special needs or disabilities.
What this form is
Use this form to ask the Salem Police Department to enter information about a person with a physical or mental impairment, disability, or qualifying health-related condition into the Premise Alert Program database. It asks for the person's contact and address details, special needs, and the submitter's name, relationship, signature, and date. The form states that the information is confidential and kept for no more than two years.
Who needs it
An individual, family member, friend, caregiver, or medical professional familiar with the person may complete and sign the form.
How to submit it
Return the completed form to the Salem Police Department at 201 S. Rotan Ave., Salem, IL 62881.
About notarization
This document is signed without a notary; there are no notarized or sworn attachments or related steps, so the signer just signs and dates it.
How to submit this form
- 1
Download the Form
Download the Premise Alert Program Enrollment Form.
- 2
Complete the Form
Print legibly and provide the person's details, special needs information, and the submitter's name and relationship.
- 3
Sign and Date
Sign and date the form to give Salem Police permission to enter the information into the program database.
- 4
Return the Form
Return the completed form to the Salem Police Department at 201 S. Rotan Ave., Salem, IL 62881.
Frequently asked questions
- What is the Premise Alert Program Enrollment Form for?
- It provides Salem Police with information about a person with special needs or a qualifying condition for entry into the Premise Alert Program database.
- Who can complete and sign the form?
- The form may be signed by the individual, a family member, friend, caregiver, or medical personnel familiar with the individual.
- Do I need a notary for the Premise Alert Program Enrollment Form?
- No. This form is signed without a notary, and it does not identify any notarized or sworn attachments or related steps.
- How do I submit the Premise Alert Program Enrollment Form?
- Return the completed form to the Salem Police Department at 201 S. Rotan Ave., Salem, IL 62881.