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2. Residents must live within city limits to utilize this form. If you live outside of Lima, please contact the Red Cross @ 260-255-3721.
4. First Name*
5. Last Name*
7. Address1*
9. City*
10. State*
11. Zip*
13. Phone Number*
14. Email address
15. Do you own or rent?*
    -- Select One --OwnRentOther
17. Please check all times and days that work well for your appointment*

    1. Mondays
    2. Tuesdays
    3. Wednesdays
    4. Thursdays
    5. Fridays

    1. Saturdays
    2. Sundays
    3. Morning
    4. Afternoon
    5. Evening
18. Please check all that apply to you*

    1. Walk in attic space
    2. Basement
    3. Upstairs
    4. one bedroom

    1. two bedrooms
    2. three bedrooms
    3. 4+ bedrooms
20. I understand this program is not able to accommodate urgent or emergency requests. It may take up to a month to get my appointment scheduled. *
    -- Select One --Yes, I understand
22. Waiver of Liability*
    -- Select One --Yes, I understand and agree

    I understand and agree that the sole purpose of this program is to help residents receive early notification of fire incidents by providing them with free smoke detectors supplied by the Red Cross and that the Lima Fire Department is providing installation as a free service of to city residents through this program. I realize that the Lima Fire Department is not responsible for the quality, safety, or condition of the free smoke detectors or of my own detectors, now or in the future. Furthermore, I understand that the actions taken in this program will not guarantee safety in a fire incident. I understand that it is important to read and follow the instruction manuals and maintenance recommendations, including when to replace, for my smoke detectors. For these reasons, I hereby release any program participants, any participating organizations or individuals from any present or future liability for any injuries or damages that may result during installation, a fire, or otherwise.

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