FLINT HILL FIRE DEPT

“OUR FAMILY
PROTECTING YOURS”
PHONE (803) 548-4805
FAX (803) 548-4901 / 1950 HWY 21
FORT MILL, SC29715 / FIRE CHIEF-DAVID JENNINGS
DEPUTY CHIEF-BRUCE BYRNES
ASSISTANT CHIEF-EDCRANFORD

FORCIBLE ENTRY RELEASE FORM

STATE OF SOUTH CAROLINA

YORKCOUNTYFHFD Incident #:______

FLINT HILL FIRE DISTRICT

I, ______(print), do hereby acknowledge that on this ______day of ______, in the year______, I requested that the Flint Hill Fire Department provide a fire apparatus response to assist me in gaining entry to the following property:

Mobile: A ______(year), ______(make), ______(model) vehicle with license plate number ______for the state of ______(abbr).

Structure: A dwelling located at ______(street address) ______(apt or suite) in the FortMillTownship of York County, SC,USA.

I further acknowledge that I am the legal owner of the above referencedproperty or am otherwise authorized by said owner to utilize such property and, therefore, I am in lawful possession of said property.

I further acknowledge that for and in consideration of the services rendered by the Flint Hill Fire Department by providing fire apparatus response to this lock-out/lock-in situation, I hereby release and forever discharge the Flint Hill Fire District, Flint Hill Fire Department or its members from any and every right, claim, or demand which may now or might otherwise arise on account of, connected with, or growing out of the Flint Hill Fire Department’s fire apparatus response to a lock-out/lock-in, including those rights, claims or demands made by me, the lawful owner of said property or a third party.

I further agree to indemnify the Flint Hill Fire District, Flint Hill Fire Department or its membersfrom any and all costs,expenses and liability which the Flint Hill Fire District, Flint Hill Fire Department or its members may incur resulting from a right, claim or demand arising out of or connected with the Flint Hill Fire Department providing fire apparatus response to a lock-out/lock-in at my request.

I understand and intend by my execution of this document to release the

Flint Hill Fire District, Flint Hill Fire Department or its members, from the liability whatsoever as a result of providing a fire apparatus to a lock-out/lock-in, including release from damage to said vehicle, other personal property and real property.

This is the ______day of ______, ______

______(signature)

______(FHFD Witness)