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Get Alarmed Installation Form for Fire Departments
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Number of individuals living in home:
UNDER 5 years old
OVER 65 years old
Have a disability
Resident MUST read and authorize the following liability waiver.
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.
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.
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.
By typing your name and date below, you attest that you understand and agree with the terms mentioned above.
Name of Adult Resident
INSTALLER, PLEASE COMPLETE THE FOLLOWING:
Resident's current smoke alarms
Number of working smoke alarms
Number of non-working smoke alarms due to:
Number of devices installed
Smoke/CO Combo Alarm
DHH Strobe Alarm
DHH Bedside Shaker
Where were device(s) installed in home?
If other, explain
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