Surry County Marcus Alert

In accordance with Virginia Law code section 9.1-193, Surry County Sheriff’s Office has established a voluntary database to assist Public Safety first responders while responding to critical incidents. This database is maintained locally and is only available to the Surry County Sheriff’s Office 911 Communications Center to provide relevant mental health and emergency contact information to those first responders during an emergency or crisis. Identifying health information concerning behavioral health illness, mental health illness, developmental or intellectual disability, or brain injury may be voluntarily provided to the database by the individual. The parent or legal guardian of an individual may provide this information if the individual is under the age of 18, but that information will be removed from the database when that individual reaches the age of 18 unless the individual or guardian requests it remains. Information is associated with the individual based on the addresses provided.

Information provided to the database shall not be used for any other purpose except as set forth above.

Contact Information

Individual First Name *

Individual Last Name *

Nickname Of Individual (if any) *

Individual Date Of Birth * +

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Emergency Contact Information

Home Phone *

Mobile Number *

Health Information

Does the individual have any of the following medical conditions? (Check all that apply) *

Behavioral Health Illness

Mental Health Illness

Developmental or Intellectual Disability

Brain Injury

Please provide a description of any diagnoses or medical condition(s) and any specific actions responders should be aware of for the health and safety of the individual and responders themselves. *

Does the individual have any allergies? *

Yes (If Yes, please list below)

No

Allergies?

Resources

Health Care Provider Name: *

Health Care Provider Contact Information *

Name of Mental Health Care Provider or Case Worker (if any): *

Mental Health Care Provider or Case Worker Contact Information: *

Intervention and wellness process or crisis/de-escalation plan: *

Person Filing This Report (If Other Than Individual)

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address

Are you the Parent or Guardian of the Individual? *

Yes

No

(If individual is under 18 years of age, is the person reporting this information the parent or legal guardian?)

If No, what is your relationship to the individual? *

Disclaimer: I understand and acknowledge that I am under no obligation to provide any of the requested information and that by completing this form I am doing so completely voluntarily. I further understand that any information submitted will be shared with first responder agencies of Surry County, including the Surry County Sheriff’s Office and the Surry Volunteer Rescue Squad. I further understand that this information may be used and relied upon by first responders when responding to a call for service.

Receive a copy of this form? *

Yes

No