Barry County United Way

Pennock Foundation

&

Blue Cross/Blue Shield

Delton, Freeport, Hastings, Hickory Corners, Johnstown, Nashville, Orangeville, Pine Lake, Thornapple Township Emergency Services & Woodland Fire Departments

Home Smoke Detector Program

This program is designed to assist families and senior citizens over the age of 55 with incomes of less than $40,000 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, Blue Cross/Blue Shield, 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 _______________

Is your income under $40,000 per year yes no

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

Signature of Landlord _______________________________________________________________________

Have you had a child born at Pennock Hospital in the last 3 years? yes no

Is the smoke detector you received currently installed in your home? yes no

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 ______ Pennock detector 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 - 450 Meadow Run Suite 300, Hastings, MI 49058 or FAX to (269)945-4536 or Hastings Fire Department. If you have any questions, please call Barry County United Way at (269)945-4010