Section 1 of 1 in this document
Drowning-Prevention Initiative: Pool Alarm Interest Form
This program is for Manatee County Residents Only. Batteries will need to be picked up pick up Tuesdays through Fridays at either the Little Discovery Center, located at 321 15th Street West, Bradenton, or the Manatee County Building, located at 1112 Manatee Avenue West.
Full Name
First Name
Last Name
Cell Number
Email
Full Address
Street Address
City
State
Zip
What are the ages of the children living with you?
0 to 3 years
4 to 5 years
6+ with special needs diagnosis*
* Please indicate the diagnosis/special needs:
I also would like to receive a two-pack of window/door alarms. I confirm that I have not received window/door alarms from Manatee County or its partners.
Yes
No
Please affirm the following statements are true.*
I am a citizen of Manatee County.
I have a pool at my residence (address listed above with ZIP Code).
I have a child within the target age range in my care at least weekly.
I currently do not have a water-surface alarm or pool gate installed.
I will not hold the County, its employees or its volunteers liable regarding use of the water-surface alarm.
The alarm is to be installed by the recipient and used used as directed with proper supervision.
All questions on installation and use are to be directed to LifeBuoy (contact information included in the device package).
All products received are provided in an effort to reduce instances of drowning.
These products are not to replace proper supervision but are provided to alert caregivers of potential risks.
I will properly install and use the alarm(s).
I acknowledge that the alarm(s) received is/are for my family’s personal use and not for resale.
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Sign Here
Sign Here
First Name
Last Name
Email
Choose how to sign
Draw
Type
I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.
disregard this