Operation: Be Alert

Person Requesting Detector(s)

Date of Request

Name

Phone Number

Address

Date of Birth

# of Children in Home

Age(s) of children

Annual Household Income of $25,000 or less

Children in Household under 14 years of age

Adults over 65 years of age

Occupant suffers from hearing/vision Impairment

Town of Jonesborough resident/Jonesborough County Fire District

Comments

QUANTITY REQUESTING:

10 Year Lithium Smoke Detector

Hearing Impaired Smoke Detector

9 V Battery Replacement

JONESBOROUGH FIRE DEPARTMENT
WAIVER AND RELEASE OF ALL CLAIMS
"OPERATION: BE ALERT!"

For and in consideration of my participation in the Town of Jonesborough Smoke Detector Program, I agree to release the Town of Jonesborough, its agents and employees and the Jonesborough Fire Department, from all claims, demands, suits and causes of action, of every nature whatsoever, on account of damage or loss to property including both real and personal bodily injuries or death , resulting from the installation, failure to operate or faulty operation of the smoke detector installed at my request by the Town of Jonesborough.

It is further understood and agreed that the Town of Jonesborough is not the insurer of the safety of those who would occupy the dwelling in which the detector is installed against the hazards of fire. While the smoke detector device is designed to warn of fires, the Town of Jonesborough makes no guarantee or warranty of any kind, including no implied warranty of merchantability of fitness, or that the fire detection system supplied will avert of prevent fires, or that the detector will timely warn of fires and related occurrences. Any such warranties, if in existence, are given by the manufacturer of the detector, and I agree, that any claims or suits for failure to operate or faulty operation of the detector will be solely against the manufacturer. Additionally, I understand that it is my obligation to purchase the batteries to operate the smoke detector as needed and to maintain the detector after installation.

By signing this full release, I hereby consent to the entry of the Town of Jonesborough's employees into my dwelling, at a mutually agreed upon time, for the sole purpose of installing the smoke detection device. The undersigned further acknowledges that the Town of Jonesborough's Fire Department and its agents or employees, expressly disclaim any liability for damage resulting from the installation of this smoke detection device; and I hereby release the Town of Jonesborough and its agents and employees from any and all claims and/or damages resulting there from. I further agree not to remove this device at any time without the expressed written consent of the Town of Jonesborough.

My typed name appearing below indicated that I have understood the above intent to be legally bound.

I agree to the above*

Signature (type name)

Date signed

Event Registration Software by RegFox

JONESBOROUGH FIRE DEPARTMENT"Operation: Be Alert!"SMOKE DETECTOR REQUEST FORM

JONESBOROUGH FIRE DEPARTMENT
"Operation: Be Alert!"
SMOKE DETECTOR REQUEST FORM