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2. Resident Name
3. Phone
5. Street Address
7. City
8. State
9. Zip Code
11. Number of individuals living in home:
13. UNDER 5 years old
14. OVER 65 years old
15. Have a disability
19. Resident MUST read and authorize the following liability waiver.
21. I understand and agree that the State of Kansas or any Kansas Fire Department is providing smoke alarms and/or carbon monoxide alarms and installing them as a public service in the interest of encouraging fire safety and helping to prevent the loss of life and property.
23. I understand that the State of Kansas or any designated Kansas Fire Department does not guarantee or endorse these brands of devices. I also understand that the State of Kansas or any designated Kansas Fire Department is not a seller, manufacturer or dealer in these devices. In exchange for accepting the free device(s) and their installation, I agree not to make any claim or demand or to file any lawsuit against the State of Kansas or any designated Kansas Fire Department or any individual employee or volunteer with the State of Kansas involved in the "State Fire Marshal Smoke Alarm Installation Program," for any injuries, deaths, damages, costs or expenses claimed to have resulted from the device(s), battery, installment or from the instructions for maintenance and safety given at the time of installation.
25. I hereby waive any cause of action that I may have now or in the future or that anyone else may have by or through me, arising out of the malfunctioning of the device(s) or batteries, whether or not used in accordance with the manufacturer's instructions. I further understand for these devices to be effective, they will need to be checked monthly. This release from liability is binding on me and my family and all my heirs, successors and assigns.
27. By typing your name and date below, you attest that you understand and agree with the terms mentioned above.
29. Name of Adult Resident
30. Date
34. INSTALLER, PLEASE COMPLETE THE FOLLOWING:
36. Resident's current smoke alarms
37. Number of working smoke alarms
39. Number of non-working smoke alarms due to:
41. No batteries
42. Outdated
43. Malfunctioning
45. Other
46. Explain
48. Number of devices installed
50. Smoke/CO Combo Alarm
51. DHH Strobe Alarm
52. DHH Bedside Shaker
54. Where were device(s) installed in home?

    1. Sleeping room
    2. Hallway
    3. Other
55. If other, explain
59. Name
60. Fire Dept./Agency
62. FDID
63. Dept. Phone
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field