Waterloo Fire Rescue Residential Key Box Request

Waterloo Fire Rescue Residential Key Box Request

These are intended for Waterloo residents who are at risk of falling AND live alone. If you do not meet these requirements, you may not be eligible for a free lock box.
Your Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*

Area CodePhone Number
Your E-mail Address
Do you rent or own the property?

OwnRent
Number Of Residents At Address Where Box Will Be Placed?*
Do you have Life Line, Life Alert, or Any Other Emergency Alert Device In Your Home?

YesNo
Has Your Doctor Determined You To Be a Fall Risk?

YesNo
What Types of Devices Do You Use For Assistance Moving on a Regular Basis?

CaneWalkerWheelchair(None of the above)
Secondary Contact

Please provide information for an additional person in the event you are unable to be contacted about the status of your key box.
Secondary Contact

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Should be Empty: