Police – Special Needs / Medical Notification Request

PIERCETON POLICE DEPARTMENT
207 N. FIRST STREET
PIERCETON, IN 46562
574.594.2232

The Pierceton Police Department strives to make our community safer for our citizens who are in need of special services. We are most successful when we know the citizen’s name and their special needs or said medical condition prior to arriving at their address.

This form is to be completed by the parent/guardian of, or power of attorney over any Pierceton Indiana resident with a diagnosed disability or said medical condition(s) for the notification purpose in our dispatch system that is used for dispatching emergency services (Police/Fire/EMS).

* *NOTE: The information gathered is part of the community policing program that the Pierceton Police Department provides to our citizens who are in need of special services. This form does NOT take the place of the SMART-911 System in Kosciusko County. All the information contained on this form shall remain strictly confidential. The information shall be used only to provide assistance to emergency medical and police responders, when it is made available to them during a call to your address in Pierceton Indiana.

The undersigned acknowledges that the information provided will not result in any type of preferential treatment to the individual and that the Pierceton Police Department, its police officers and any other responding agencies will not be held liable for additional duties relating to information provided herein.

I understand and agree to these terms hereby grant permission for the Pierceton Police Department to enter the information included in this form onto the listed individual’s name file in the police department’s central dispatch database for safety and emergency response purposes.

I understand that if any of the above information changes I must notify the Pierceton Police Department by filing an amended request form. It is my responsibility to update and renew the form if I want the information up to date for use with emergency responders.

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New contact or amended?: *

• New
• Amended

Contact information for person in needs of special services: *

First

Last

Physical Address: *

DOB:

Home Phone

Cell Phone *

Emergency Contact Information: *

First

Last

Emergency Contact Physical Address: *

Relationship: *

Emergency Contact Phone *

Email *

Physician Contact Information:

First

Last

Physician Address:

Physician Phone:

Hospital Associated With:

Explanation of Special Needs: *

Considerations During Interaction: *

Submitter Information: *

First

Last

NOTE – Must be a parent / guardian / custodian or appointed legal representative.

Physical Address: *

Relationship: *

Submitter Phone: *

* * Signature: *

By typing your name here, you agree to the special note above.

Date / Time *

Submit