Medical Alert Form

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	Medical Alert Form

Alert Notification Form

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York County 9-1-1 has the ability to document medical conditions or special needs of individuals in our Computer Automated Dispatch System. Having this information is beneficial to both you and the emergency responder; this includes fire, police, and medical. The information provided will be kept on file for one year. A new form will be mailed annually (January 1st) to verify the continued need for your information to be maintained. NOTE: By submitting this form, it is comparable to a legal signature.
Name of Residence / Business
Street Address
City
Zip Code
Phone Number
Special Requirements
Emergency Contact Name
Emergency Contact Phone
Date

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