300 W Ash, Salina, KS, 67401, US
If you are a parent, guardian, caregiver or individual with medically diagnosed special needs, please complete the following form to participate in the program. Answer all questions completely and accurately, as this information will be utilized to create the alert in our database. If you have a question regarding any portion of the form, send an email to email@example.com and firstname.lastname@example.org.
Date of Birth
Please upload a recent photo of the individual that includes only their head and shoulders. If possible, also send a digital version of the photo (png or jpeg format) to email@example.com and firstname.lastname@example.org. Make sure to include the individual's name and date of birth in the email.
Please check all that apply.
Which of the following apply to this individual? Check all that apply.
Address of School or Daycare
S.A.Id. Participation Form completed by:
By submitting this form, I certify that the information provided is true and accurate to the best of my knowledge. I understand that I voluntarily provided the information listed within this form and that it will not result in any type of preferential treatment from first responders. I hereby grant the Salina Police Department to create an alert utilizing the above information and consent to that information being shared with the Salina Fire Department and the paramedics and ambulance service.
Authorization for Alert