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2. This form allows Roanoke Fire-EMS to collect the information required to provide smoke alarms to your home.

   Roanoke Fire-EMS offers free smoke alarms to homeowners who are unable to purchase them on their own, based on availability.  To qualify for the program, you must live in the City of Roanoke.

   Remember - check your smoke alarms once a month & practice your home fire escape plan!

4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
12. Phone Number*
14. How many people live in your home?*
15. List ages of each occupant.*
16. Do you need smoke alarms?*

    1. Yes
    2. No
17. Do you need batteries for existing alarms?

    1. Yes
    2. No
19. How did you hear about the program?*
20. Are you the homeowner or renter?*

    1. Owner
    2. Renter
21. Does anyone in the home smoke?*

    1. Yes
    2. No
22. How many levels (including basement) does your home have?*
24. How many bedrooms does your home have?*

    Please only count the bedrooms that someone sleeps in every night. Do not include spare bedrooms, or bedrooms converted for other uses.

26. OPTIONAL - Does anyone in your home have a disability that could make it hard to escape from a fire or other emergency?

    1. Yes
    2. No

    This question is optional and would only be used to help determine whether you may need additional follow-up about other services the City can provide to your home.

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32. Questions?

    Contact the Fire Marshal's Office at (540)853-2795 or [email protected].

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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field