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2. GENERAL INFORMATION

4. The Emergency Needs Database, also known as the Marcus Alert, provides residents and businesses the opportunity to voluntarily provide information to emergency services agencies concerning individuals with special needs. Should an emergency occur, our emergency services responders will be better able to serve them. The information collected is only shared with emergency services agencies and is not disclosed to the public. This form will need to be resubmitted every year.

8. First and Last Name of Person Submitting Information*
9. Phone Number*
11. First and Last Name of Person Identified for the Emergency Needs Database*
12. Name of Business Identified for the Emergency Needs Database
14. Address*
16. City*
17. State*
18. Zip Code*
20. Cell Phone Number*
21. Home Phone Number*
23. Date of Birth of Person Identified for the Emergency Needs Database*

    Date of Birth is mandatory if the medical information being provided is for a juvenile. Per law, such information will be removed upon the person reaching the age of 18, unless the individual requests it to be retained in the database.

24. Gender*

    1. Female
    2. Male
    3. Other
25. If other, please specify.
27. Information you would like to voluntarily provide for Emergency Service to have in the event you call 911 for service.*
31. In the event Emergency Services needs to contact a family member, or business owner/keyholder, please provide the following information.
33. Contact First and Last Name*
34. Contact Phone Number*
36. Relation to Person Identified for the Emergency Database*

    Ex: mother, father, sibling, guardian, friend, keyholder, owner, etc.

40. By submitting this information, you agree to give local law enforcement personnel, Office of Emergency Management desgnees and responders permission to enter your home in case of an emergency to assist in care and/or evacuation.

    Please check your information before submitting this form.

Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field