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Residential Emergency Response Form
Do you – or someone you know -- need assistance during an emergency? Do you know someone who has advanced medical conditions, is in a wheel chair, non-verbal, visually impaired, hearing impaired or someone with severe allergies etc?  The Residential Emergency Response Form may be helpful to you.

The Residential Emergency Response Form provides important medical circumstance details and contact information of trusted individuals who can assist emergency responders when entering or securing your home during an emergency.  It provides access information such as lock box or garage codes to be added to your address. This form is particularly helpful to first responders making them aware about your distinct and special circumstances prior to arriving on scene.

How does it work
?  Fill out the form and submit to Centre County 911. The information is entered into our CAD Alerts (Computer Aided Dispatch) system based on your address listed on the form. When you dial 911 for help, these “notes” will automatically generate on the CAD screen for dispatchers to see and relay to first responders as needed. One important item to note, contacts listed on the form are not phoned for every 911 call; the contact information is listed as a resource only and provided to responders if needed. To discuss this item in more detail, call Centre County 911 at 355-6800 and ask for Barbara.


  • This information will only be shared with emergency responders during an emergency at the address listed on the form.
  • It may be relayed electronically, or by radio, to police officers, firefighters, paramedics, or other emergency responders by the staff at the Centre County 911 Emergency Communications Center.
  • Completing the Residential Emergency Response Form, and providing the personal information it includes, is entirely voluntary.
  • Centre County 911 will not place any notes on record without a completed form (signature required).
  • You can revoke the release of this personal information at any time, in writing. 
  • It is the resident’s responsibility to provide updates or changes to 911 (if you move, we can transfer the “remarks” to your new address)
  • Residential Emergency Response Form has a 6 month review process which is done by email.  
  • A written reply is mandatory during the 6 month review.  If there is no response, the “remarks” are removed from record automatically and the Residential Emergency Response Form is discontinued. 
  • If you have questions or wish to update your information, or to revoke/discontinue your notes, call Barbara at 355-6800.

Residential Emergency Response Form

You can submit the form several ways: fax, email or U.S. Postal Service.

Centre County 911                              Fax:  814-355-6776

ATTN:  Barbara

420 Holmes Street                              email: 
Bellefonte, PA  16823