Smoke Alarm Request
and Liability Waiver and Release

Please read and sign:

Smoke alarms are your first line of defense, but they can only save your life in they are in working condition:

· Install smoke alarm on every level of your home

· It is best to have alarms near each sleeping area

· Test alarms monthly

· Maintain your alarm according to manufacturer’s instructions



In consideration of the Pike Township Fire Department (PTFD) donating, installing, and/ or giving instructions on how to install the smoke alarm devices at no expense to myself, by my signature, I, , hereby authorize the Pike Township Fire Department (PTFD) to install or supply smoke alarms in the residence listed above. I understand and agree that PTFD is providing smoke alarms as a public service in the interest of encouraging fire/life safety and helping to prevent needless injury and/or loss of life and property. I hereby agree to indemnify and hold harmless PTFD and the officers, agents, and employees from any liability of loss, either direct or consequential, arising out of any act or omission of mine or another person’s occurring in connection with or as part of my maintenance and control over donated smoke alarms devices and the premises where they are installed.

By my signature below, I knowing and without mental reservation hereby release and hold harmless Pike Township Fire Department and its officers, agents, and employees from any and all liability, either direct or consequential, arising out of accidents, injuries, occurrences, or losses to me in connection with smoke alarm devices, their installation, maintenance, or operation.


  • Please enter your name as your electronic signature.