McCullom Lake, IL · McHenry County
Premise Alert Program Registration Form
This form lets a person with special needs, or someone familiar with them, register, change, or remove information for emergency responders.
What this form is
The form enrolls a person in the Premise Alert Program so information about special needs can guide police, fire, and EMS personnel responding to an emergency. Use it to register, change, or remove information. It asks for identifying and contact details, employment or educational facility information when applicable, special needs, the signer’s relationship to the person, and a signature and date; the information expires after two years.
Who needs it
A person with special needs, or a family member, friend, caregiver, or medical person familiar with them, can submit this form.
How to submit it
Download the form from the district website or pick it up at McCullom Lake Village Hall. Complete it and return it to the McCullom Lake Police Department, 4811 W. Orchard Drive, McCullom Lake, IL 60050.
About notarization
This document is signed and dated without a notary; it does not mention a notarized or sworn attachment or related step.
How to submit this form
- 1
Download The Form
Download the form from the district website or pick it up in person at McCullom Lake Village Hall.
- 2
Complete The Form
Choose new, change, or remove information and fill in the applicable details about the person and their special needs.
- 3
Sign And Date
Print the signer’s name, state their relationship to the person, and sign and date the form.
- 4
Return It To The Police Department
Return the completed form to the McCullom Lake Police Department at 4811 W. Orchard Drive, McCullom Lake, IL 60050.
Frequently asked questions
- What is the Premise Alert Program form for?
- It provides information about a person with special needs to public safety responders, including police, fire, and EMS personnel.
- Who can complete the registration form?
- The signer may be the person named on the form, a family member, friend, caregiver, or medical person familiar with that individual.
- How do I submit the Premise Alert Program form?
- Complete it and return it to the McCullom Lake Police Department at 4811 W. Orchard Drive, McCullom Lake, IL 60050.
- Do I need a notary for the Premise Alert Program form?
- No. The form asks for a signature and date but does not require a notary or mention a notarized or sworn attachment.