© 2017 by Fire & Burn Safety Coalition of Maryland

Hard of Hearing Alarm Application

To participate in this program, you must  

  • Answer all questions, on both the front and back sides of this form 

  • Be a Maryland resident with a hearing impairment

  • Provide proof of your need (letter from doctor, medical provider, audiologist, professional, etc.) NOT live in an institutional facility (dorm, nursing home, etc.)

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Do you have a contact person who you would rather us contact for scheduling and followup requirements?

Yes

Information Regarding the Residence 

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Does the Residence Have Any of The Following?

Does the Residence Have Currently Working Smoke Alarms?

Yes

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Preferred Method of Contact?

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Upload Your Proof of Need Here

Choose File
Max File Size 15MB

DISCLAIMER:

This program is operated on limited funding and generous donations. We ask those who are capable,

please donate to this needed program to help those less fortunate. These devices retail for approximately $300.00 each.

Any contributions to offset the costs are greatly appreciated. Thank you!

You Can Make contributions by check payable to: FABSCOM – DHH Fund or use our paypal link below.

Information collected is kept confidential and used for follow-up by FABSCOM only.