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Who can use it?
              Anyone who has a special need, health challenge or disability such as, but not limited to, Alzheimer’s Disease, Autism,
              Mental Health Challenges, Intellectual Disability, a complex or rare medical condition, who would like first responders such as
              police, ambulance and fire department to know of their special needs.

Who can fill out this form?
•            Individuals with special needs can fill it out for themselves
•            Parents of minor children
•            Guardians of minor children
•            Current Foster Care parents (child’s name isn’t required)
•            Those with LEGAL guardianship for another
•            Those with the Power of Attorney for another
              If you do not have a legal right to provide this information, you should NOT fill out this form or provide this information.

Do I have to fill it out?
              No, it is VOLUNTARY. You do not have to provide any information you do not want First Responders to know or use.

How do I use the form?
              Fill out the form with as much information as you would want shared with emergency first responders, sign it, and then return
              a copy to your child’s teacher and the school will send all forms in to the local police department or you may mail it back to
              your local police department. The information will be put into the police system for future use.

What Police Department should I send it to?
              If you reside in:
•            Emmaus Borough: Emmaus Police Department, Attention: Chief David Faust, 400 Jubilee Street, Emmaus, PA 18049
•            Alburtis Borough: Alburtis Police Department, Attention: Chief Robert Palmer, 260 Franklin Street, Alburtis, PA 18011
•            Macungie Borough: Macungie Police Department, Attention: Chief Edward Harry, 21 Locust Street, Macungie, PA 18062
•            Lower Macungie Township: Pennsylvania State Police, Attention: Lieutenant Edgardo A. Colón, Troop M -
             Fogelsville Station, 8320 Schantz Road, Breinigsville, PA 18031
•            Upper Milford Township: Pennsylvania State Police, Attention: Lieutenant Edgardo A. Colón, Troop M - Fogelsville
             Station, 8320 Schantz Road, Breinigsville, PA 18031

The form asks for a recent photograph, what kind of picture is best?
             Any picture is better than no picture, but the best picture is a close-up of the person’s face. A passport or school picture
             would suffice. It is best if the background is plain.

How often do I need to fill out a Premise Alert Form?
             This form is good for 1-2 years depending on the system it is filed in. If you move or need to make changes in the
             information, just fill out another form and submit it. Any of the police departments will automatically use the new information.

For more information, please visit http://www.papremisealert.com/

The Premise Alert System and Form is a collaboration between Chief Kevin McCarthy, Susan F. Rzucidlo, Law Enforcement Entities, disability advocates, parent volunteers, educators, State & County Officials and other interested parties. It is owned by SPEAK Unlimited Inc. and is protected by copyright laws. It has been given free of charge to the state of Pennsylvania. PERMISSION: You are permitted and encouraged to reproduce and distribute this material in hardcopy or electronic form provided that you do NOT alter the wording in any way, you do not charge a fee beyond the cost of reproduction, you give credit to the original authors, and receive written permission and approval from Chief Kevin McCarthy or Susan F. Rzucidlo if alterations or changes are being recommended for incorporation. More information on this program and additional resources can be found at www.papremisealert.com contact srz@dol.net © 2004-7.

Emmaus Borough Hall, 28 South 4th Street, Emmaus, PA 18049 | (610) 965-9292

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