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