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? The Residential Emergency Response Form may be helpful to you.

This form provides important medical details and contact information for 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. All information submitted is completely confidential.

How Does It Work?

The information is based on your address listed on the form. When you dial 911 for help, the alert automatically generates in the Computer Aided Dispatch (CAD).

Plesae Note:

  1. Information is relayed to responders on an as needed basis.
  2. The contact information is listed as a resource only and provided to responders if they request it. Contacts are not notified of every 911 call.
  3. Spacing is limited. Only list life threatening and/or pertinent details.

Should I List Medication?

No. You Should not list your medications. This information becomes outdated quickly. Have a prepared list of your medications and health history for EMTs when they arrive on scene. Keep it posted on your refrigerator so it's ready in the event of an emergency. EMTs will need this information for their assessment.

A Few Things to Be Aware of:

  • Centre County 911 will not place any alert notes on record without a completed form (signature required).
  • This information will only be shared with emergency responders -- during an emergency at the address listed on the form.
  • Information – if relayed – will be done by the staff at Centre County 911. It could be relayed electronically, or by radio, to police officers, firefighters, paramedics, or other emergency responders.
  • Completing the Residential Emergency Response Form, and providing the personal information it includes, is entirely voluntary.
  • 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 as long as you reside in Centre County).
  • The form is reviewed with the requestor every 6 months, 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 and the Alert is discontinued.
  • You can revoke the release of this personal information -- cancel at any time, in writing.
  • If you have questions or wish to update your information, or to revoke/discontinue your notes, call 355-6800.

Residential Emergency Response Form (PDF)

Mailing Address:
Centre County 911 Addressing
420 Holmes Street Bellefonte, PA 16823
Fax: 814-355-6776
Email Barbara Berenty