Frankfort Fire Protection District

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*****