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Residential Emergency Contact Form

Residential Emergency Contact Formwp-support2021-02-02T10:47:22-06:00

**All information provided is confidential for emergency service personnel only and is in accordance with (430 ILCS 132/) Illinois Premise Alert Program (PAP) Act.**

Resident #1
First Name*
Last Name*
Business / Work Number*
Cell Phone Number*
Resident #2
First Name
Last Name
Business / Work Number
Cell Phone Number
Home Telephone*
Address*
Apt / Lot
City / Zip*
Owner Information If different than above
First Name
Last Name
Address
City / Zip
Home Phone
Business Phone
Cell Phone
Keyholder Information Family or neighbors, living nearby, who have keys to your home in an emergency
Do you have an exterior key lock box?*
- Yes
- No
If yes, where is it located?
Person - #1
Name
Address
City / Zip
Phone
Cell
Person - #2
Name
Address
City / Zip
Phone
Cell
Person - #3
Name
Address
City / Zip
Phone
Cell
General Information
The house is how many stories (not including basement)?*
Please enter a number from 1 to 40.
Basement?*
- Yes
- No
Do you have a private fire alarm system?*
- Yes
- No
If yes, Fire alarm company name?
Phone
Account #
Reset Code
(Reset codes are needed in the event that you are not home and we need to silence the alarm)
Where is the alarm panel located? (please be exact)
Do you have a fire sprinkler system?*
- Yes
- No
Where is the water shut off for the sprinkler?*
Additional Information

Please list ALL occupant(s) members
Person #1
Name
Date of Birth
MM slash DD slash YYYY
Special needs/Disabilities? (Please provide details)
Where does everyone sleep? (include outside window locations)
Person #2
Name
Date of Birth
MM slash DD slash YYYY
Special needs/Disabilities? (Please provide details)
Where does everyone sleep? (include outside window locations)
Person #3
Name
Date of Birth
MM slash DD slash YYYY
Special needs/Disabilities? (Please provide details)
Where does everyone sleep? (include outside window locations)
Person #4
Name
Date of Birth
MM slash DD slash YYYY
Special needs/Disabilities? (Please provide details)
Where does everyone sleep? (include outside window locations)
Person #5
Name
Date of Birth
MM slash DD slash YYYY
Special needs/Disabilities? (Please provide details)
Where does everyone sleep? (include outside window locations)
Person #6
Name
Date of Birth
MM slash DD slash YYYY
Special needs/Disabilities? (Please provide details)
Where does everyone sleep? (include outside window locations)
Person #7
Name
Date of Birth
MM slash DD slash YYYY
Special needs/Disabilities? (Please provide details)
Where does everyone sleep? (include outside window locations)
Can we find you?
Where is your address posted on your property (please be exact)
Hazards to Emergency Responders
Any dogs on premises?*
- Yes
- No
Name(s)
Any dangerous/exotic pets?*
- Yes
- No
Type:
Indoor or in-ground pool?*
- Indoor
- In-ground
- No pool
(location if indoor)
Any dangerous chemicals (other than normal household supplies) stored in your home? If yes, please list them below (Name and approximate amount):
CAPTCHA

Information

Main Office
1970 Plainfield Rd.
La Grange Highlands, IL 60525

Contact us

Business Hours
Mon - Fri: 7:30am to 4:00pm
(708) 352-9229

Copyright © 2016 Pleasantview Fire Protection District