Deaf or Hard of Hearing Alarm Device Application

Fire and Burn Safety Coalition of Maryland (FABSCOM) - Alarm Devices for Deaf or Hard of Hearing

FABSCOM helps Maryland residents with a qualified need to obtain a home alarm set-up that offers a visual and sensory alarm to alert them if their smoke or Carbon Monoxide alarm activates.
To request help obtaining an alarm set-up and participate in this offering we need you to answer all questions and then submit the application
Applicants receiving help must be Maryland residents and certify they are deaf or hard of hearing
This application will ask you to upload certification of need in the form of a letter from a doctor, medical provider or audiologist certifying your need for these assistive alarm set-ups
Applicants living in institutional facilities such as dorms, nursing homes, assisted livings, etc, cannot be considered as part of the FABSCOM assistance.
Privacy Information collected is kept confidential and used for follow-up by FABSCOM only.
Date of This Request

MonthDayYear
Date

Contact Person/Guardian

Please provide a contact person if you need assistance with scheduling the alarming device installation.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How is the contact/guardian related to the applicant?*

Fire and Burn Safety Coalition of Maryland (FABSCOM) - Alarm Devices for Deaf or Hard of Hearing