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2. MARCUS ALERT 911 VOLUNTARY DATABASE
4. Name*
5. DOB*
   DOB
7. Home Address*
9. City*
10. State*
11. Zip*
13. Work/School/Other Address
15. City
16. State
17. Zip
19. Phone Number*
20. Phone Number (alternate)
24. COMPLETE THIS SECTION ONLY IF REPORTING ON BEHALF OF THE INDIVIDUAL
26. Are you the parent or guardian of the person being registered?
    -- Select One --YESNO
28. Name of Person Reporting Information
29. Phone Number
33. Emergency Contact Name
34. Emergency Contact Phone Number
38. Health Information

    Do you have one of the following conditions or diagnoses? Check all that apply.

    1. Health Condition
    2. Mental Health Diagnosis

    1. Developmental or Intellectual Disability
    2. Traumatic Brain Injury
40. Please Provide a description of any diagnosis, health condition, or disability:
42. Medications:
46. Important Information for First Responders

    What happens during a crisis? Detail stressors or triggers for the individual. Is there a crisis plan? How can first responders help during a crisis? Detail anything else relevant to first responders.

48. In compliance with Va. Code Section 9.1-193(F), each locality shall establish a voluntary database to be made available to the 9-1-1 alert system and the Marcus alert system to provide relevant mental health information and emergency contact information for appropriate response to an emergency or crisis. If you are an individual with the behavioral health illness, mental health illness, developmental or intellectual disability, or brain injury; the parent or legal guardian of such individual if the individual is under the age of 18; or a person appointed the guardian of such person, you may voluntarily provide identifying and health information concerning behavioral health illness, mental health illness, developmental or intellectual disability, or brain injury to this database. Provision of such information is completely voluntary. This information will be made available only to the 9-1-1 alert system and the Marcus alert system.

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50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

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