Rev. v3.03-18
LAKE COUNTY EMERGENCY MANAGEMENT
NATIONAL OCEANIC & ATMOSPHERIC ADMINISTRATION (NOAA)
WEATHER RADIO PROGRAM ENROLLMENT FORM
NAME: DATE:
AGENCY/ DEPT/ ORGANIZATION:
ADDRESS:
CITY: STATE: ZIP CODE:
PHONE:
Program Criteria/ Eligibility
Lake County Office of Emergency Management offers this service on a first-come, first-served basis to eligible residents when
funding sources and supplies exist. The NOAA Weather Radio Program is available to Lake County residents that fall into the
Federal Poverty Guideline.
In the table below, please select the number of persons living in your household.
2018 Federal Poverty Guidelines
DISCLAIMER AND LIABILITY RELEASE (MUST BE SIGNED TO PARTICIPATE)
By signing this document, the undersigned resident has requested this service and will allow Emergency Management personnel to
provide an NOAA weather radio programmed to the
Specific Area Message Encoding (SAME) designated for Lake County.
NOAA weather radios are effective in warning residents of fast- moving storms such as severe thunderstorms and tornadoes.
However, the NOAA weather radio has to be properly maintained. Your responsibility is to keep the weather radio positioned for
optimum reception, plugged in and batteries replaced at a minimum of once yearly or when the device indicates a low battery.
I also agree to receive severe weather information and educational materials during this visit for the added safety of the
occupants of my residence, and myself; and that I, my heirs and legal agents do hereby release Lake County and all agencies,
organizations,
institutions or individuals who are now or who may become associated with this service from any and all liability for
damages, injury or casualty of any sort whatsoever involving my residence, my property, myself, or any other person which results or may
result from activities conducted directly or indirectly for this service.
Signature: ________________________________________________________________ Date: ______________________________
A NOAA Weather Radio can be picked up in person from our office located at 425 W. Alfred St. Tavares, FL 32778. PLEASE CALL OUR OFFICE
352.343.9420 TO SCHEDULE AN APPOINTMENT. Completed forms may be emailed to disasterready@lakecountyfl.gov.
To Be Completed by Emergency Management Staff Only
Approve Not Approved General Fund Grant Funded Bed Shaker Strobe Light
Serial Number: Weather Radio: Midland WR-120 EZ
Emergency Management Representative Signature: ___________________________________________________ Date: ______________________
