Emergency Identification Bracelet Program

The Oak Park Police Department distributes silicone bracelets that can help break down communication barriers during emergencies when first responders encounter individuals with autism, Alzheimer's, dementia or other mental health issues.

Bracelets are available on a voluntary basis to any Oak Park resident with a medical or mental health concern that may benefit from this program.

After submitting this form, you will be contacted to schedule an appointment to receive the bracelet.

All information provided is confidential. If an emergency arises, the information on the ID bracelets will only be released to first responders and emergency medical staff. No personal information is included on the bracelet.

For more information, contact the Police Department at 708.386.3800 or police@oak-park.us.

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Name *

Address *

Phone number *

Gender *

Race *

Birth date *

Emergency contact #1 name *

In the event of an emergency, the following person(s) should be notified:

Relationship to the emergency contact *

Emergency contact address *

Emergency contact phone number *

Emergency contact #2 name

Relationship to the emergency contact #2

Emergency contact #2 address

Emergency contact #2 phone number

Emergency contact #3 name

Relationship to emergency contact #3

Emergency contact #3 address

Emergency contact #3 phone number

Physician's name *

Physician's phone number *

Physician's address *

Allergies (if any) *

Primary medical conditions (if any)

Medications taken regularly

Please list medications taken regularly, you do not need to indicate dosage

Additional helpful information

Helpful hints for first responders, ex. calms down with music, likes trucks, etc.

Certification

Name of person completing form *

Phone number of person completing form *

Email of person completing form *

DISCLAIMER *

I hereby give my permission to the Oak Park Police Department and the West Suburban Consolidated Dispatch Center (WSCDC) to release the information contained on this form to authorized persons in cases of emergency in accordance with the purpose of this program. Please indicate that you have read and understand the disclaimer by selecting "Yes."

Yes

Leave this field blank

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Emergency Identification Bracelet Program

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