CONFIDENTIAL SPECIAL NEEDS FORM

Print this form and fill it out, fax or mail to

Frankfort Fire Protection District

333 W. Nebraska Street

Frankfort, IL 60423

Attn: A/C Larry Rauch

Confidential Special Needs Citizens Emergency Medical Information Form

Name:

Phone:

Address:

SPECIAL NEEDS:

Visually Impaired

Hearing Impaired

Speech Impaired

Paraplegic

Wheelchair/Bed Confined

Other (Please be Specific):

*****PLEASE KEEP A CURRENT LIST OF ALL MEDICINES ON THE SIDE OF THE REFRIGERATOR FOR PARAMEDICS*****