May 2, 2013

Vacation Premise Alert Form

The Vacation Premise Alert Form


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.  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.


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.  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.  Ask for a direct phone number to the police station and program it into your cell phone for the duration of your trip.


When your family is going on vacation, print and fill this form out and attach a recent photo of your special needs individual.  Provide only the most important information for first responders regarding the special needs individual.


Where is asks for medical condition list only the most significant diagnosis.


Provide your VACATION ADDRESS NOT your home address. List a room number if appropriate.


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.  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.


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’s officer.   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.


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.  Also, ask who will act upon the information you are supplying.


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.




The “CRITICAL MEDICAL INFORMATION FORM” can be found at    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.  That form is freely downloaded and may be reproduced.


Photo ID’s that show family and child together in a home setting.  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.


Teach your child carry a wallet and how to use an ID card.


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.




























We will be vacationing in your town or resort from _____________________to __________________  Please destroy this form after our departure date.


Please make your officers aware that a special needs individual is visiting your area and may require additional assistance.


Name and birth date of individual:

Nombre y fecha de nacimiento del la persona:


_______________________________________________________ attach recent

Photo here

Current physical description of individual:                                                                   foto  reciente

Una descripcion fisica actual de la persona: Male [ ]       Female [ ]

Height___________ Weight______________

Altura                    Peso

Eye color______________ Hair color______________

color de pelo                       color de ojo


Scars or other identifying marks:

Cicatrices u otras marcas que identifican:________________________________________________




Any Medical conditions:  Cualesquiera condiciones [ ] Blind/Persiana    [ ] Deaf/sordo  


   [ ] Mental Retardation/Retraso Mental    [ ] Mental Illness/Enfermedad mental    [ ] Autism  


[ ] Physical Disability/Inhabilidad fisica   [ ] Diabetes   [ ] Seizure/ataque   [ ] Alzheimer’s 


 [ ] Other/Otro:____________________________________________


 Prescription medications needed:

medicación médicas de la prescripción: ___________________________________________________


Name of parents or care providers:__________________________________________________________

Nombre de padres o cuidado del nino:


Address/Dirección ________________________________________________________________________


Phone numbers/Número de teléfono:

Home/ Casa _______________________________ Cell phone/ Teléfono cellular _____________________


Pager/Beeper   ___________________________ TDD/TTY_______________________________________

Name of alternative emergency contact person:

Alternativa de la persona del contacto Nombre: _________________________________________________


Phone numbers/Número de teléfono:    Home/ Casa__________________________________


Work/ Trabajo________________________ Cell phone/ Teléfono de la célula _________________________


Pager/ Beeper__________________________   TTY/TDD_________________________________________


Is he/she likely to wander off?

¿El o ella le gusta vagar en diferentes sitios? __________________________________________________


Favorite attractions or locations where they may be found:

Localizaciones preferidas en donde pueden ser encontrados:_______________________________________




Atypical behaviors or characteristics that may attract attention:

Comportamientos o características anormales que pueden atraer la atención:___________________________




Favorite toys, objects or discussion topics likes, dislikes:

Juguetes preferidos, objetos o asuntos de discusión que le gustan o no le gustan:_______________________





Approach, calming or de-escalation techniques most likely to work:

Técnicas del acercamiento para calmarlo: ______________________________________________________





Method of communication, if nonverbal, sign language, picture board, written words:

Método de comunicación, si no es verbal, lenguaje por signo, palabras escritas, letreros:_________________





ID information. Do they carry or wear jewelry, tags, ID card:

Información de  identificación. Usan joy as, etiquetas, tarjeta de identificación: ________________________




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 household who has a disability. There is no guarantee that this information will be accessed in the event of an emergency. 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

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