The Vacation Premise Alert Form<\/b><\/p>\n
<\/p>\n
Going on a vacation is a wonderful opportunity, but worrying about safety issues when traveling with someone who has special needs can be overwhelming for families.\u00a0 The Vacation Premise Alert Form was developed to help families and caregivers provide critical medical and behavioral information to First Responders when traveling away from home. The Vacation Premise Alert Form was developed in 2003 by myself, Susan Rzucidlo and Police Chief Kevin McCarthy, to date I’ve not heard of a single family who had it turned away by any police department when they attempted to provide this information.<\/p>\n
<\/p>\n
You will need to take time to explain to the Officer about the need for a Premise Alert for your family member and how you would like that information provided to officers. Ask the Officer to announce the Premise Alert and about the special needs of your family member at shift change and to post the form nearby in case an emergency call needs to be made.\u00a0 It is unlikely that a department would share this information with the county 911 Center for a short vacation. If the special needs your family member lives with is medical in nature you can ask the Police Department to fax a copy of your form to the EMS department so they have it on hand.\u00a0 Ask for a direct phone number to the police station and program it into your cell phone for the duration of your trip.<\/p>\n
<\/p>\n
When your family is going on vacation, print and fill this form out and attach a recent photo of your special needs individual.\u00a0 Provide only the most important information for first responders regarding the special needs individual.<\/p>\n
<\/p>\n
Where is asks for medical condition list only the most significant diagnosis.<\/p>\n
<\/p>\n
Provide your VACATION ADDRESS NOT your home address. List a room number if appropriate.<\/p>\n
<\/p>\n
Write a CELL PHONE NUMBER THAT YOU CARRY WITH YOU AS WELL AS A LAND LINE PHONE NUMBER OF THE ADDRESS YOU ARE STAYING AT. NOT Your home phone number.\u00a0 An additional contact person who can assist first responders will be helpful as well. That person could be a neighbor, family member, or case manager.<\/p>\n
<\/p>\n
Upon arriving in the town where you are going to vacation, make one of your first stops the local police station. Ask to speak to a community relation\u2019s officer.\u00a0\u00a0 Explain that you have a special needs individual and you will be in the area on vacation. Give them a copy of the form and ask them to let their officers know during shift change.<\/p>\n
<\/p>\n
If you are staying in a resort ask the Front Desk Attendant, or the Concierge who is the most appropriate person at the resort to receive the information and if they are the ones who contact First Responders if there are services required outside of the resort.\u00a0 Also, ask who will act upon the information you are supplying.<\/p>\n
<\/p>\n
When you leave, be sure to call to the Police Department or security staff to tell them they can destroy the form and to thank them for their assistance even if you didn’t need to make an emergency call.<\/p>\n
<\/p>\n
OTHER TRAVELING TIPS<\/p>\n
<\/p>\n
The “CRITICAL MEDICAL INFORMATION FORM\u201d can be found at www.papremisealert.com\u00a0\u00a0\u00a0 That form includes spaces for medical information, your name, and additional contact #’s and names, preferred hospital, doctors name and number, a list of medicines and the best way to communicate. In the event, a caregiver or the driver is unable to provide necessary information to First Responders that form will give them basic information and assist them in their efforts.\u00a0 That form is freely downloaded and may be reproduced.<\/p>\n
<\/p>\n
Photo ID\u2019s that show family and child together in a home setting.\u00a0 Both parents and child carry a copy in either a wallet or pocket. If a tantrum in a public setting occurs and the police or security guards come you will be able to prove that this child or adult is supposed to be with you. It could prevent a long wait in a security office or police station.<\/p>\n
<\/p>\n
Teach your child carry a wallet and how to use an ID card.<\/p>\n
<\/p>\n
Buy a medic alert bracelet and have them wear it. If they won’t or can’t you can string it through shoes or put it on a belt or zipper pull.<\/p>\n
<\/p>\n
<\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
\u00a0<\/b><\/p>\n
VACATION PREMISE ALERT REQUEST FORM<\/b><\/p>\n
\u00a0<\/b><\/p>\n
We will be vacationing in your town or resort from _____________________to __________________\u00a0 Please destroy this form after our departure date.<\/span><\/b><\/p>\n \u00a0<\/span><\/b><\/p>\n Please make your officers aware that a special needs individual is visiting your area and may require additional assistance. <\/b><\/p>\n \u00a0<\/b><\/p>\n Name and birth date of individual:<\/p>\n Nombre y fecha de nacimiento del la persona:<\/p>\n <\/p>\n _______________________________________________________ attach recent<\/p>\n Photo here<\/p>\n Current physical description of individual:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 foto\u00a0 reciente<\/p>\n Una descripcion fisica actual de la persona: Male [ ]\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Female [ ]<\/p>\n Height___________ Weight______________<\/p>\n Altura\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0Peso<\/p>\n Eye color______________ Hair color______________<\/p>\n color de pelo\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 color de ojo<\/p>\n <\/p>\n Scars or other identifying marks:<\/p>\n Cicatrices u otras marcas que identifican:________________________________________________<\/p>\n <\/p>\n _______________________________________________________________________________________<\/p>\n <\/p>\n Any Medical conditions:\u00a0 Cualesquiera condiciones [ ] Blind\/Persiana\u00a0\u00a0\u00a0 [ ] Deaf\/sordo\u00a0\u00a0 <\/b><\/p>\n \u00a0<\/b><\/p>\n \u00a0\u00a0 [ ] Mental Retardation\/Retraso Mental\u00a0\u00a0\u00a0 [ ] Mental Illness\/Enfermedad mental\u00a0\u00a0\u00a0 [ ] Autism\u00a0\u00a0 <\/b><\/p>\n \u00a0<\/b><\/p>\n [ ] Physical Disability\/Inhabilidad fisica\u00a0\u00a0 [ ] Diabetes\u00a0\u00a0 [ ] Seizure\/ataque\u00a0\u00a0 [ ] Alzheimer\u2019s\u00a0 <\/b><\/p>\n \u00a0<\/b><\/p>\n \u00a0[ ] Other\/Otro:____________________________________________<\/b><\/p>\n \u00a0<\/b><\/p>\n \u00a0Prescription medications needed:<\/b><\/p>\n medicaci\u00f3n m\u00e9dicas de la prescripci\u00f3n: ___________________________________________________<\/b><\/p>\n <\/p>\n Name of parents or care providers:__________________________________________________________<\/p>\n Nombre de padres o cuidado del nino:<\/p>\n <\/p>\n Address\/Direcci\u00f3n ________________________________________________________________________<\/p>\n <\/p>\n Phone numbers\/N\u00famero de tel\u00e9fono:<\/p>\n Home\/ Casa _______________________________ Cell phone\/ Tel\u00e9fono cellular _____________________<\/p>\n <\/p>\n Pager\/Beeper\u00a0\u00a0 ___________________________ TDD\/TTY_______________________________________<\/p>\n Name of alternative emergency contact person:<\/p>\n Alternativa de la persona del contacto Nombre: _________________________________________________<\/p>\n <\/p>\n Phone numbers\/N\u00famero de tel\u00e9fono:\u00a0\u00a0\u00a0 Home\/ Casa__________________________________<\/p>\n <\/p>\n Work\/ Trabajo________________________ Cell phone\/ Tel\u00e9fono de la c\u00e9lula _________________________<\/p>\n <\/p>\n Pager\/ Beeper__________________________\u00a0\u00a0 TTY\/TDD_________________________________________<\/p>\n <\/p>\n Is he\/she likely to wander off?<\/p>\n \u00bfEl o ella le gusta vagar en diferentes sitios? __________________________________________________<\/p>\n <\/p>\n Favorite attractions or locations where they may be found:<\/p>\n Localizaciones preferidas en donde pueden ser encontrados:_______________________________________<\/p>\n <\/p>\n _______________________________________________________________________________________<\/p>\n <\/p>\n Atypical behaviors or characteristics that may attract attention:<\/p>\n Comportamientos o caracter\u00edsticas anormales que pueden atraer la atenci\u00f3n:___________________________<\/p>\n <\/p>\n _______________________________________________________________________________________<\/p>\n <\/p>\n Favorite toys, objects or discussion topics likes, dislikes:<\/p>\n Juguetes preferidos, objetos o asuntos de discusi\u00f3n que le gustan o no le gustan:_______________________<\/p>\n <\/p>\n _______________________________________________________________________________________<\/p>\n <\/p>\n <\/p>\n Approach, calming or de-escalation techniques most likely to work:<\/p>\n T\u00e9cnicas del acercamiento para calmarlo: ______________________________________________________<\/p>\n <\/p>\n _______________________________________________________________________________________<\/p>\n <\/p>\n <\/p>\n Method of communication, if nonverbal, sign language, picture board, written words:<\/p>\n M\u00e9todo de comunicaci\u00f3n, si no es verbal, lenguaje por signo, palabras escritas, letreros:_________________<\/p>\n <\/p>\n _______________________________________________________________________________________<\/p>\n <\/p>\n <\/p>\n ID information. Do they carry or wear jewelry, tags, ID card:<\/p>\n Informaci\u00f3n de\u00a0 identificaci\u00f3n. Usan joy as, etiquetas, tarjeta de identificaci\u00f3n: ________________________<\/p>\n <\/p>\n _______________________________________________________________________________________<\/p>\n <\/p>\n<\/div>\n Your answers to these questions MAY assist police, fire, or medical personnel when they are responding to an emergency or other call from your home, in identifying and\/or assisting you, or a person in your <\/b>household who has a disability. <\/b>There is no guarantee<\/b> that this information will be accessed in the event of an emergency. <\/b>This form is owned by SPEAK Unlimited Inc and is protected by copyright laws. PERMISSION: You are permitted and encouraged to reproduce and distribute this material in any format if you do NOT alter the wording in any way, you do not charge a fee beyond the cost of reproduction, and you give credit to the author. (c) 2003-11 for more safety information go to our website\u00a0 www.papremisealert.com<\/p>\n Or e-mail SPEAKSusan@gmail.com<\/p>\n","protected":false},"excerpt":{"rendered":" The Vacation Premise Alert Form Going on a vacation is a wonderful opportunity, but worrying about safety issues when […]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"_ti_tpc_template_sync":false,"_ti_tpc_template_id":"","footnotes":""},"class_list":["post-5498","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.thepremisealert.com\/us\/wp-json\/wp\/v2\/pages\/5498","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.thepremisealert.com\/us\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.thepremisealert.com\/us\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.thepremisealert.com\/us\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.thepremisealert.com\/us\/wp-json\/wp\/v2\/comments?post=5498"}],"version-history":[{"count":2,"href":"https:\/\/www.thepremisealert.com\/us\/wp-json\/wp\/v2\/pages\/5498\/revisions"}],"predecessor-version":[{"id":5800,"href":"https:\/\/www.thepremisealert.com\/us\/wp-json\/wp\/v2\/pages\/5498\/revisions\/5800"}],"wp:attachment":[{"href":"https:\/\/www.thepremisealert.com\/us\/wp-json\/wp\/v2\/media?parent=5498"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}