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2. Intro

   Marcus Alert Voluntary Database – City of Roanoke

   In accordance with Virginia Law, the City of Roanoke provides this form allowing citizens to submit information into a voluntary database.  This database is available to the City of Roanoke E911 center to provide relevant mental health information and emergency contact information to our Public Safety responders in an emergency or crisis.  Identifying and 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 they reach the age of 18 unless the individual or guardian requests it remain.  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.

4. Individuals Name: *

   Provide the name of the individual that the information provided applies to.

6. Individuals contact phone number: *

   Provide the primary contact number for this individual so we can contact for any questions.

8. Residential Address:*
10. Work/School address
12. Other Address frequently visited by the individual:
14. Address Instructions

    All above addresses must include the full street name including quadrant of the city (NE, NW, SE or SW) along with any building, apartment or room numbers.  Note this information is only available to responders within the City of Roanoke.  

16. Date of Birth:
18. Parent or Guardian?

    1. Yes
    2. No

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

20. Reporting Name:

    Name of person reporting this information if different than then above:  

22. Reporting person contact phone number:
24. Emergency contact name:
26. Emergency contact phone number:
28. Health information: *

    Explain the appropriate health information and any specific actions responders should be aware of for the health and safety of the individual and responders:

Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit Submit and Print

* indicates a required field