Greenup County Public Safety S.A.F.E.R. Program

This form allows you to notify first responders of any medical conditions or other circumstances that may require additional resources or specific responses from first responders. Please fill out as much information as possible. If you have any questions, please feel free to contact our non-emergency number at 606-473-1411.

Identifying Information:

First name

Last name

Address

PHONE

BIRTHDAY

Month

Day

Year

SEX

NICKNAME:

EYE COLOR:

HAIR COLOR:

SCARS/IDENTIFYING MARKS:

Emergency Contact Information:

Person to be contacted in the event of an emergency involving the person. Note: Public Safety Staff will initially validate information and repeat on an annual basis.

First Name:

Last Name:

Address

Phone

Relation to Person

Medical Conditions:

Please check all that apply.

Medications

Additional Information:

ADDITIONAL NOTES/SPECIAL INSTRUCTIONS:

In cases of missing or lost persons, having a current photo on file will save time for first responders. Upload a current photo to have on file here.