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2. Notice

   The only requirement for being eligible to receive smoke alarms is that you must live within Henry County. If you live outside of Henry County please contact the corresponding agency for your area.

4. Name*
6. Address*
8. City*
9. State/Province/Region*
11. Postal/Zip Code*
12. Country*
14. Phone Number*
16. Email
18. Type of Heat in the Home*

    Select all that apply.

    1. Electric (Heat Pump, Baseboard Heat, Space Heater, Etc.)
    2. Kerosene
    3. Natural Gas
    4. Oil Furnance
    5. Propane
    6. Wood
20. How many people live in the home?*
22. How many people under the age of 17 live in the home? *
24. How many people over the age of 65 live in the home? *
26. Are there individuals with a disability, access, or funtional needs living in the home?*

    1. Yes
    2. No
28. How many pre-existing smoke alarms do you have in the home? *
30. If you have alarms, how many are currently working?
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field