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No More Falls Program Request Form

  1. Aptos - La Selva Fire District

  2. This form is to request services via the "No More Falls Program", dependent on resident needs. Residents can request a self-check form to be mailed to their home, or for a qualified inspector to do a home visit to identify fall hazards within the residence.

  3. Preferred Inspection Method*

    Check One

  4. For those requesting a home inspection, list available dates and times. Allow 2-4 weeks for scheduling.

  5. Leave This Blank:

  6. This field is not part of the form submission.