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City of Salina

support@salina.org

300 W Ash, Salina, KS, 67401, US

S.A.Id. Participation Form

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 wayne.pruitt@salina.org and amber.pfeifer@salina.org.

Please provide information on the individual who will have the S.A.Id. Alert

Full Name

Date of Birth

Address

Descriptive Information

Please provide vehicle information on the individual who will have the S.A.Id. Alert

Photo

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 wayne.pruitt@salina.org and  amber.pfeifer@salina.org. Make sure to include the individual's name and date of birth in the email.

Upload Photo

Individual's Special Needs

Please check all that apply.

Which of the following apply to this individual? Check all that apply.

School or Daycare Information (if applicable)

Address of School or Daycare

Primary Emergency Contact

Full Name

Date of Birth

Address

Secondary Emergency Contact

Full Name

Date of Birth

Address

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