EMERGENCY PHONE INFORMATION PAGE

THE INFORMATION YOU PROVIDE BELOW WILL HELP THE LIVINGSTON COUNTY SHER-
IFF’S OFFICE, EMERGENCY COMMUNICATIONS CENTER, RESPOND TO YOUR CURRENT LO-
CATION IF YOU’RE HAVING AN EMERGENCY AND CALL 911 FROM YOUR CELL OR SMART
PHONE WITHIN LIVINGSTON COUNTY. NOTE: A LAND LINE PHONE WILL SHOW YOUR
HOME LOCATION ONLY BUT CAN PROVIDE YOUR SUBMITTED INFORMATION BELOW.

YOUR INFORMATION CAN BE UPDATED OR DELETED UPON YOUR WRITTEN REQUEST.

PLEASE CAREFULLY PRINT YOUR INFORMATION BELOW

1) LAST NAME: ________________________________ FIRST NAME:___________________ M.I.: _______
2) YOUR DATE OF BIRTH in case someone else has the same name (mm/dd/yyyy): _________________________
3) YOUR HOME’S STREET ADDRESS: _________________________________________________________
4) CITY: ________________________________ (Livingston County, NY) ZIP CODE: ________________
5) YOUR CELL / SMART PHONE NUMBER WITH AREA CODE: __________________________________

6) YOUR LAND LINE PHONE NUMBER WITH AREA CODE: _____________________________________

7) YOUR VEHICLE LICENSE NUMBER(s): ______________________________________________________
8) DO OTHER PERSONS live in your home? If YES, print their name(s), age and phone number with area
code: ________________________________________________________________________________________
9) DO YOU HAVE A DOG? YES - NO HOW MANY? ____ CIRCLE SIZE: Small - Medium - Large

10) EMERGENCY CONTACT PERSON’S NAME AND PHONE NUMBER(s) WITH AREA CODE:
______________________________________________________________________________________________
11) YOUR DOCTOR’S NAME: __________________________________________________________________
12) YOUR DOCTOR’S PHONE NUMBER: _______________________________________________________

13) CIRCLE or PRINT your SIGNIFICANT medical conditions/handicaps: (Examples are Heart Conditions,
Pacemaker, Blood Pressure, Diabetes, Allergies, Require Oxygen, COPD, Wheel Chair, Bedridden, FILE OF LIFE
packet in / on my Refrigerator, Etc.): ______________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

YOUR SIGNATURE: ___________________________________________

DATE: (mm/dd/yyyy): _______________________

Thank you for helping us help you when

you have an emergency and call 911.
Thomas J. Dougherty
Livingston County Sheriff

PLEASE RETURN OR MAIL THIS FORM TO:

EMERGENCY COMMUNICATIONS CENTER
LIVINGSTON COUNTY SHERIFF’S OFFICE
4 COURT STREET, GENESEO, NY 14454
911 INFORMATION PAGE 2018
 Livingston County Sheriff’s Office
Enhanced Emergency Communications Center
PHONES WILL NOT AUTOMATICALLY PROVIDE MEDICAL AND EMER-
GENCY INFORMATION WHEN YOU CALL 911 IN LIVINGSTON COUNTY.
YOUR VOLUNTARY INFORMATION CAN BE VERY IMPORTANT TO RESPOND-
ERS SUCH AS POLICE, FIRE OR AMBULANCE PERSONNEL. ALL INFORMA-
TION WILL BE KEPT ON THE LIVINGSTON COUNTY EMERGENCY COMMU-
NICATIONS CENTER COMPUTERS. YOUR VOLUNTARY INFORMATION CAN
BE SEARCHED BY THE 911 OPERATOR IF NEEDED. THE CENTER WILL DE-
LETE OR UPDATE YOUR INFORMATION UPON YOUR WRITTEN REQUEST.

A Critical Need
The population of Livingston County, NY on July 1, 2016 as estimated by the U.S.
Census Bureau was 64,257. The number of residents age 65 and over was 10,795 or 16.8%. It
is generally accepted that older persons are a higher risk group in respect to medical and
emergency 911 calls.

A Solution
New technology can now often provide the Livingston County Sheriff’s Office, Emer-
gency Communications Center (911) operator an incoming cell/smart phone’s location any-
where within Livingston County. Your home land line phone will provide the Emergency
Communications Center with your home address location ONLY, but can provide the other
information you write on the EMERGENCY PHONE INFORMATION PAGE. The VOL-
UNTARY data on the Emergency Phone Information section on the other side of this page
will provide additional information for the emergency responders (medical, police, fire).

Just fill out the form, sign and date it, and mail or return the form to
the Emergency Communications Center, Livingston County Sheriff’s Office,
4 Court Street, Geneseo, NY 14454. There is no charge nor obligation to sub-
mit the form.

911 Emergency Information Page 2018