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2. Contact Information of Person being added to the Marcus Alert Database

4. First Name*
5. Last Name*
7. Address*
9. City, State and Zip*
   -- Select One --Charles City, Virginia 23030Providence Forge (Charles City County), Virginia 23140Ruthville (Charles City County), Virginia 23147Richmond (Charles City County), Virginia 23231Williamsburg (Charles City County), Virginia 23185
11. Phone Number*
12. Alternate Phone Number
14. Date of Birth*
15. Gender*
    -- Select One --MaleFemaleUnknown

19. Emergency Contact Information

21. Emergency Contact - First Name*
22. Emergency Contact - Last Name*
24. Emergency Contact Phone Number*
25. Emergency Contact Alternate Phone Number*

29. Health Information

31. Do you have any of the following medical condition(s):*

    1. Health Illness
    2. Mental Health Illness
    3. Developmental or Intellectual Disability
    4. Brain Injury

    (Check all that apply)

33. Please provide a description of any diagnoses or medical condition(s)*
35. Do you have any allergies?*

    1. Yes
    2. No
37. If yes, please list your allergies
39. Other important information

43. Resources

45. Health Care Provider - First Name
46. Health Care Provider - Last Name
48. Health Care Provider - Phone Number
49. Health Provider Email Address
51. Mental Health Care Provider(s) or Case Worker(s)
53. Medications
54. Stressors
56. Prevention and Wellness Process or Crisis Plan
58. Anything else that would be helpful for a responder to know in order to assist you?

62. Individual Completing This Form

64. If you are completing this form for someone else please provide the following information:

66. First Name*
67. Last Name*
69. Relation to individual for whom you are filling out this form:*
71. Phone Number*
72. Email Address*
74. Consent*
    -- Select One --I agree

    I understand and acknowledge that I am under no obligation to provide any of the requested information and that by filling out this form I am doing so completely voluntarily. I further understand that any information that I submit will be shared with agencies of the County of Charles City, including the Charles City County Sheriff's Office, and the Charles City County Fire and EMS / Volunteer Fire Department. I further understand that this information may be used and relied upon by first responders and other individuals responding to a call for service.

Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field