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Smoke Alarm Installation

  1. Service Acknowledgement Form
  2. Did the resident(s) create a fire escape plan?
  3. Did the resident(s) review the Home Fire Safety Checklist?
  4. Did the resident(s) learn about a local hazard?*
  5. Resident Certification
    I am a resident of the home located at the address found above. I acknowledge that today I received the services indicated in the Services Provided section. I have also received instruction in the proper used and maintenance of smoke alarms.I understand that smoke alarms make a sound to warn persons in my home in the event of a fire, but that smoke alarms work only if they have been properly maintained. It is my responsibility to maintain the smoke alarms in my home per the manufacturer's recommendations and to test my smoke alarms monthly. It is also my responsibility to make sure that I have the appropriate number of smoke alarms in my home and that the smoke alarm is are in appropriate locations. The American Red Cross and its partners are not responsible for determining teh appropriate number or placement of smoke alarms. Your signature indicates that you have read the information above and that you agree with its content.
  6. How many people live here?
  7. Is a bedside alarm needed for people who are deaf or hearing impaired?*
  8. Optional Reporting Fields
  9. National Coalition Organization(s)
  10. Local Coalition Organization(s)
  11. Did the client provide contact information?
  12. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  13. Administrative Section
  14. Has this record been entered into the online portal?
  15. Leave This Blank: