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Home Safety Check Information

Home Safety Check Information

About
Home Safety Check Request Form

About

The home safety check program is designed to provide and install smoke alarm(s) free of charge* to Orange Beach residents who own and live in the requested home. Factors considered for providing this service are:

Not having a working smoke alarm in the home
Not being financially able to purchase alarms
Having at least one child under the age of 18
Having anyone over 60 years of age living in the home
Not being physically able to install an alarm on your own

To request assistance from the home safety check program, please click on the "Smoke Alarm Installation Request" tab above.

Please note: The Orange Beach Fire Department cannot assist or replace hard-wired smoke alarms. Please contact a licensed electrician.

*While supplies last

Home Safety Check Request Form

Home Safety Check Request Form

This form has been modified since it was saved. Please review all fields before submitting.

Steps

1. Personal Information This section is complete This section is incomplete
2. Home Information This section is complete This section is incomplete

Personal Information

Name*
Email Address*
Address*
City*
Phone number*
Number of people in the home who are disabled*
Is anyone in the home deaf or hard of hearing?*
1. Yes
2. No
Number of people in the home under the age of 20*
Number of people in the home between the ages of 20 and 65*
Number of people in the home over the age of 65*
Is anyone in the home a veteran?*
1. Yes
2. No
Continue

Home Information

Type of dwelling*
1. Single family residence
2. Mobile home
3. Other
If other, please describe
Number of floors in the home*
Ceiling Height*
Please describe the highest ceiling height in your home
Age of the home*
Your preferred method of delivery*
1. Installation
2. Self-installation
If installation, what is a good day/time for the visit?
Brief description *
For example, how many smoke alarms do you need? Are your current smoke alarms hard-wired or battery? If they use batteries, which type of battery do you need? Do you have smoke alarms on each level of the home? Outside each living space? Are they less than 10 years old?
Comments
RESIDENT MUST READ AND SIGN THE FOLLOWING LIABILITY WAIVER
I understand and agree that the Orange Beach Fire Department is providing smoke alarms and installing them as a public service in the interest of encouraging fire safety and helping to prevent loss of life and property. I understand that the Orange Beach Fire Department does not guarantee or endorse this brand of smoke alarm. I also understand that the Orange Beach Fire Department is not a seller, manufacturer, or dealer in smoke alarms. In exchange for accepting the free smoke alarm and its installation, I agree not to make any claim or demand or to file any lawsuit against the Orange Beach Fire Department, the City of Orange Beach, or any individual employee or volunteer with the Orange Beach Fire Department involved in the home safety check program for any injuries, deaths, damages, costs or expenses claimed to have resulted from the smoke alarm, battery, installment, or from the instructions for maintenance and safety given at the time of installation. 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 smoke alarm or batteries, whether or not used in accordance with the manufacturer's instructions. I further understand that in order for these smoke alarms to be effective, the alarm will need to be checked monthly. This release from liability is binding on me and my family and all my heirs, successors and assigns.
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.
1. I agree.
Electronic Signature*

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

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City of Orange Beach
4099 Orange Beach Boulevard
Orange Beach, AL 36561
Phone: 251-981-6979

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