Residential Emergency Response Form

Do you – or someone you know have a serious medical illness or has vulnerable needs?  The Residential Emergency Response Form may be effective for you or someone you know. This form is particularly helpful to first responders making them aware of your distinct circumstances prior to arriving on scene.   Access information such as lock box or garage codes can also be added to your alert to assist them when entering or securing your home during your emergency. All information submitted is completely voluntary


For purposes of the Residential Emergency Response Form, the definition of a medical emergency is a serious illness or disease, that, if not treated right away, could cause serious harm to you or death.  

For the purposes of the Residential Emergency Response Form, the definition of vulnerable needs is a person or people who are susceptible to harm, with access and functional needs (physically, visually or hearing impaired) that may interfere with their ability to receive medical care before during and after an emergency or disaster; persons who have difficulty communicating (non-verbal, autistic).

How Does It Work?

The information is based on your address listed on the form. When you dial 9-1-1 for help and provide your address, the alert automatically displays in a pop up window (we call “toast”) on the CAD screen.   

Plesae Note:

  1. Information is relayed to responders as needed.  
  2. Spacing is limited. Only list life altering, life-threatening details that meet criteria of this form’s definition of a medical emergency (listed above).
  3. Please do not list personal contact and their information.  This information will not be included in your alert; 911 will not notify family members of the 911 call. 

Should I List Medication?

No.  Do not list your medications or your doctor. We strongly recommend you have a prepared list of your medications and health history for EMTs when they arrive on scene. Keep it up-to-date and posted on your refrigerator.  EMTs will need this information if you call 9-1-1 for help.  

Oxygen Patients:  if you are on oxygen, please notify Centre County Emergency Management 814-355-6745. Centre County EMA tracks this information.

A Few Things to Be Aware of:

    • Centre County 911 will not place any alert on record without a completed form (signature required).
    • This information will only be shared with emergency responders -- during an emergency at the address listed on the form.
    • Information – if relayed – will be done by the staff at Centre County 911. It could be relayed electronically or by radio, to police officers, firefighters, paramedics, or other emergency responders.
    • Completing the Residential Emergency Response Form, and providing the personal information it includes, is entirely voluntary.
    • It is the resident’s responsibility to provide updates or changes to 911 (if you move, we can transfer the “remarks” to your new address as long as you reside in Centre County.)
    • The information provided will be reviewed with the requestor every six (6) months.  Be sure to provide a valid email address and current phone number.   
    • A written email reply is mandatory during the 6 month review.  If there is no response, the “remarks” are removed from record and the Alert is discontinued. 
    • You can revoke the release of this personal information -- cancel at any time.  Send letter to Centre County 911 Alerts, Willowbank Bldg, 420 Holmes St, Bellefonte, PA 16823; or email to: addressing@centrecountypa.gov.  
    • If you have questions or wish to update your information email addressing@centrecountypa.gov, or mail the information to Centre County 911 Alerts, Willowbank Bldg, 420 Holmes St, Bellefonte, PA 16823.
    • Personal Contact information will not be included in your alert; 911 will not notify family members of the 911 call. 

Residential Emergency Response Form (PDF)
Residential Emergency Response Form Information (PDF)