Cascades – Smoke Alarm Request_EN

Cascades – Home Fire & Wildfire Education Request
Both programs offer Free Smoke Alarms

Please note, this form is for residents of this region ONLY. To learn about Red Cross services in other states, please contact your local chapter.
Solicitud educación gratis.
Name (Nombre)

First NameLast Name
Check All That Apply
Address (Dirección)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County (condado)
Email (Correo electrónico)
example@example.com
Daytime phone (Número de teléfono en el día)
Please enter a valid phone number.Format: (000) 000-0000.
Mobile phone (Número de teléfono celular)
Please enter a valid phone number.Format: (000) 000-0000.
Type of dwelling (Tipo de vivienda)
# of smoke alarms in home (Con cuantas alarmas de humo pre-existentes ya cuenta el hogar?)
How many people live in your home? (Cuantas personas viven aqui?)
How many youth under 17? (Cuantos menores de edad con edades de 17 anos y menos viven aqui?)
How many adults over 65? (Cuantas adultas con edades de 65 anos o mas viven aqui?)
Appointment preference – day (may choose one or both) Preferencia de cita – día (escoja uno o más)
Appointment preference – time (may chose multiple) Preferencia de cita – hora (escoja uno o más)
Please provide any additional information:
Is there anyone in your household who is deaf or hard of hearing?
Preferred language (Idioma preferido)
Referred by someone? (Referido por alguien?)
If yes, who? (Si es asi, quien)
Should be Empty:

Cascades – Home Fire & Wildfire Education Request