Mission Fire Department Smoke Alarm Liability Release Form printable pdf download

Mission Fire Department

Smoke Alarm Liability Release Form

I understand and agree that the City of Mission Fire Department is providing a free smoke alarm as a public service in the

interest of promoting safety and that the City of Mission Fire Department is not a seller, manufacturer, or dealer of smoke

alarms, and does not warranty, guarantee, certify or endorse this or any other brand of smoke alarm.

I verify that the new smoke alarm is in working condition at this time and that I have received and read a copy of the

manufacturer’s owner’s manual.

I understand and accept the responsibility and maintaining the smoke alarm in

accordance with manufacturer’s instructions, including checking each alarm unit monthly for proper operation. I further

understand that in order for the smoke alarm to be effective, I need to replace and install the battery as specified by the

manufacturer. As the owner, I am responsible for providing the batteries and any other necessary maintenance.

I understand that having only one smoke alarm in my home does not give me a level of protection that is considered

adequate according to the newest standards, or provides the mínimum level of protection required by the Building Code

for existing dwellings.

I exchanged for accepting a free smoke alarm and/or home assessment, I do hereby release and discharge the City of

Mission, Texas and the Mission Fire Department and its officers, agents, and employees from any and all actions, causes

of action, claims, demands, damages, costs, or losses arising from the use of said smoke alarm and/or home

assessments. Therefore, I agree not to make any demand or claim or file any lawsuit agianst the City of Mission or the

Mission Fire Department and it’s officer, agents and employees in connection with this smoke alarm/home assessment

program.

I have read and understand the above provision. The terms and provisions of this questionnaire and release are binding

on me, my legal representatives and all of my successors, assignees, heirs and estate.

_____________

______________________

_____________________

___________________

Date

Recipient Signature

Witness Signature

Unit

Applicants Name: __________________________________________

Address (required): ________________________________________

City: _________________

Zip:______________

Action Taken:

Alarm Installed

Battery Installed

Alarm Checked

Home Assessment

__________________

____________________

_______________________

Alarm Make

Model Number

Manufacture Date

Mission Fire Department Smoke Alarm Liability Release Form

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