2. Clay Fire Safe Senior Program

   The goal is to reduce fatalities and bring awareness among seniors within the territory.  The Safe Senior program will reduce kitchen fires within the senior community and allow for quicker access for emergency personnel for emergency calls.

4. Name*
6. Address*
8. City*
9. State*
   -- Select One --IN
10. Zip Code*
12. Phone Number*
13. Email*
15. How many floors in the residence?*
16. How many bedrooms?
18. Do you need Smoke Detectors?*

    1. Yes
    2. No

    Are they older than 10 years?  Have the batteries been replaced within the last year?

19. Do you need Carbon Monoxide Detectors?*

    1. Yes
    2. No

    Are they older than 10 years?  Have the batteries been replaced within the last year?

21. Clay Fire will provide a Knox HomeBox (mini vault for house key), would you like a Wall or door hanger?*

    1. Door Hanger
    2. Wall Mount
22. 
24. Clay Fire will provide a Cooktop supression unit, What is above your stove?*

    1. Vent
    2. Microwave
    3. Nothing
    4. Do not want it
25. 
27. Would you like an address sign?*

    1. Yes
    2. No
28. If yes, what style?

    1. Vertical
    2. Horizontal
29. 
31. What is a good time to follow up with you to schedule a time for installation?
33. Thank you!

    Someone from the Community Risk Reduction Division will give you a call to verify all the information.  When the fire department comes out, they will walk around with you and do a home safety survey before doing the installations.  

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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field