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Medical Alert Information Form

  1. Medical Condition

  2. Allergies

  3. Electronic Signature Agreement*

    By checking the "I agree" box below, I hereby authorize law enforcement, fire/rescue, and EMS/ambulance to enter my residence, if it is believed that I am in need of assistance and incapacitated. I also acknowledge that it is my responsibility to notify Clinton County Central Dispatch of any modifications to stated information on this form.

  4. Leave This Blank:

  5. This field is not part of the form submission.