Barry County Free Home Smoke Detection Program

Fire Departments: Bellevue,Caledonia, Delton, Freeport, Hastings, Hickory Corners, Johnstown, Lake Odessa, Nashville, Orangeville, Prairieville Township,

Thornapple Township Emergency ServicesWoodland Fire Depts.

This program is designed to assist families that are in need of smoke detectors in their homes.

By signing below you are requesting your area fire department personnel to enter your home and provide an evaluation of your current smoke detectors and install additional smoke detectors as deemed necessary.

By signing below, recipient agrees to read and follow the smoke detector instructions found in the owner=s manual at all times.

By signing below, recipient and anyone acting on his/her behalf knowingly and willingly agrees to fully release, hold harmless, defend and indemnify Barry County United Way, Hastings Kiwanis, Pennock Health Services and Pennock Foundation, all fire departments listed above and its employees, together with the officers, employees, agents, successors, assignees, subsidiaries, divisions, and affiliates of these entities from all costs, claims and liabilities which in any way may be related to recipients referral, acquisition and use of the smoke detector provided to him/her as part of this offer.

Name ______

Address______City & Zip______

Phone# ______Best time to reach you______AM or PM

Responding Fire Department (if known)______

Age of residents in home:______Age of home______

# of smoke detectors currently in home ______

Do you ownrent your home (If rental, signature of landlord is required)

Signature of Landlord ______

I attest to the validity of all information above

Signature______Date______

For Fire Department use only

Fire Department ______

Fire Personnel names ______

# of smoke detectors checked ______# of smoke detectors installed______

# of batteries installed ______

other______

I, the homeowner/renter of this home at the above address understand the information I have been given and agree to keep smoke detectors in working order ______Date______

Return application to Barry County United Way - 231 S. Broadway, Hastings, MI 49058 or FAX to (269)945-4536, or your local fire department.

If you have any questions, please call Barry County United Way at (269)945-4010.