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Heads Up! Program Application

  1. To provide information to public safety agencies related to an individual's disability, medical issue, mobility, or other condition of which emergency responders should be aware. This does not take the place of an individual's responsibility to plan and prepare for transportation and/or sheltering in the event of an emergency. All information provided will remain completely confidential and will be used only by authorized personnel to assist in an emergency.

  2. Personal Information

  3. Elevator?

  4. Ramp?

  5. Emergency Contacts

    Must provide at least one phone number.

  6. Special Need Details - Check all that apply to applicant's condition.

  7. Mobility

  8. If bedridden, may the applicant be moved by wheelchair?

  9. Communication

    1. Life-Sustaining Medical Equipment

    2. Other Needs

    3. Emergency Alert / Medical Alert / Life Call Device

    4. Home Health Care Agency

    5. Authorization*

      I understand this information will be utilized to plan appropriate care and treatment during an emergency. I understand that only those persons who have a need to know this information will have access to it. I understand that it is my responsibility to keep the provided information current. I understand I am responsible for all expenses incurred in association with medical evaluation and special sheltering in a hospital or nursing facility. I accept the conditions as specified and grant permission for Danville Fire Department to record this information in the Computer Aided Dispatch system for reference and to release this information to emergency response agencies via two-way radio in the event of an emergency.

    6. Please type full name.

    7. Leave This Blank:

    8. This field is not part of the form submission.