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2. Resident Name*

   First and last

4. Street Address*
6. City*
   -- Select One --Gulf Shores
7. State*
   -- Select One --Alabama
8. Zip Code*
10. Telephone*
11. Email Address
13. Type of Residence*

    1. Single Family Dwelling
    2. Mobile Home
    3. Other
15. Age of your home*
16. Number of levels in your home*
    -- Select One --1234
18. Number of bedrooms in your home*
    -- Select One --12345678910
20. Number of people living in your home under 20 years old:*
21. Number of people living in your home 20 to 65 years old:*
22. Number of people living in your home over 65 years old:*
23. Number of disabled people living in your home:*
25. Number of working alarms currently present in your home*
26. Number of non-working smoke alarms currently in your home*
28. Non-working alarms due to

    1. dead batteries
    2. no batteries
    3. outdated
    4. malfunction
    5. not sure
30. Reason for request*
32. Program Qualifications
    • The dwelling must currently have no working smoke alarms. 
    • The dwelling must be owner-occupied.
    • The property must be a single-family dwelling in the City of Gulf Shores.
    • The homeowner must be home during the time of installation.
    • The homeowner requesting installation will be required to complete an application and sign a waiver on the day of installation.
    • The homeowner requesting installation will be required to create a Community Connect profile. - Community Connect is a safe and secure online program available at no cost to our residents. It allows residents to provide our firefighters and emergency personnel with critical property and occupant information to help us better serve you during an emergency. For more information on Community Connect, visit www.gulfshoresal.gov/communityconnect.
34. RESIDENT MUST READ AND AGREE TO THE FOLLOWING LIABILITY WAIVER*

    1. I have read and agree to the statement below.

36. I understand and agree that the Fire Department is providing smoke 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 Fire Department does not guarantee or endorse this brand of smoke detector. I also understand that the 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 Fire Department or any individual employee or volunteer with the Fire Department involved in the "Smoke Alarm Installation Program", for any injuries, deaths, damages, costs or expenses claimed to have resulted from the smoke detector, 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.

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

    This field is not part of the form submission.

40. Submit

* indicates a required field