Team Firestopper Program. at No Cost to You, We Would Like to Demonstrate Some Simple Changes

Team Firestopper

Application

The American Red Cross of Greater Chicago is making homes fire resistant with our

Team Firestopper program. At no cost to you, we would like to demonstrate some simple changes

in the home that will help you protect your family against fire.

As a Team Firestopper client, the fire safety good and services you will receive are free of charge. Please answer ALL the questions on the reverse side to apply for the program. Applications are accepted on a first come, first serve basis. Only the first XX confirmed applicants that submit their applications are guaranteed to receive all of our fire safety materials.

To be eligible you MUST live in the Name community within the following

zip codes: XXXXX or XXXXX

Team Firestopper will be in community on Date

The seminar takes place at Name of location

Address

City, State, Zip

Once you have completed the application, please fax it to the American Red Cross at (312) 729.XXXX or mail it to the address below:

Attn: Team Firestopper

American Red Cross of Greater Chicago

2200 W. Harrison

Chicago, IL 60612

If you have any questions about this application, please call (312) 729.XXXX

------Tear here ------Tear here ------Team Firestopper Activities

Seminar participants will receive the following upon completion of ALL stations.

-  A smoke detector, with information on how and where to install and maintain it.

-  A fire extinguisher, with information on where to store it, how to operate it and how to

maintain the extinguisher.

-  A carbon monoxide detector, with information on where it should be placed.

-  A Red Cross Disaster Supply Kit.

-  Insulating window film for increased heating efficiency.

-  Development of a Family Disaster Plan.

All demonstration and services will be done by trained volunteers and/or licensed and insured professionals.

Name: (First, Last)

Address: (#, Street, APT. City, State, Zip)

Telephone Number: ( ) -

Do you own or rent your home? OWN / RENT

Is there a NEED for someone to assist with language/interpretation needs?

YES / NO If yes, what language?

How were you referred to the Team Firestopper program?

How many floors are in your home? ______How many individuals live in the home? ______

How many individuals in the home are; over 65______under 18 ______?

------Tear here ------Tear here ------

(Keep this portion)

Team Firestopper will be in community on Day,

Date at Location from X:00 xm – X:00 xm.

If you have any questions about this application, please call (312) 729.XXXX.